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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702352
Report Date: 12/30/2024
Date Signed: 12/30/2024 02:34:30 PM

Document Has Been Signed on 12/30/2024 02:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:VALLEY PINESFACILITY NUMBER:
430702352
ADMINISTRATOR/
DIRECTOR:
HEINAN, JAMESFACILITY TYPE:
740
ADDRESS:545 EAST MAIN AVENUETELEPHONE:
(408) 779-2855
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 49CENSUS: 15DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Carolyn HeinanTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 12/30/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Carolyn Heinan and explained the purpose of the visit.

LPA toured the facility inside and outside including a random sample of resident rooms, common areas, activity room and kitchen area. While touring the facility it was observed that the temperature was at 72 deg F. Hot water was also tested in the resident rooms and the temperature was 112 deg F. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floor. Resident call buttons are functioning. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter.

Five resident records and three staff records were reviewed. Resident records are updated, complete and signed. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested the following to be emailed: Liability Insurance.

LPA received a copy of Deed..

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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