<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201796
Report Date: 10/07/2022
Date Signed: 10/07/2022 12:37:29 PM

Document Has Been Signed on 10/07/2022 12:37 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:NUEVA VISTAFACILITY NUMBER:
435201796
ADMINISTRATOR:WEINSTEIN, MICHAELFACILITY TYPE:
735
ADDRESS:18225 HALE AVENUETELEPHONE:
(408) 465-8280
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 72CENSUS: 66DATE:
10/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Juan CooperTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open an initial complaint investigation. During visit, a case management – deficiencies visit was conducted. LPA met with Administrator, Juan Cooper.

During complaint investigation, it was found the facility did not report to the Department resident (R1)’s AWOL incident from the beginning of September 2022.

Based on interview, S1 states to have written the incident report but the incident report had not been sent to the Department. During visit, LPA obtained a copy of the incident report.

Based on record review, the Department did not receive a written incident report or telephone call to report R1's AWOL.

The facility did ensure to inform R1’s county conservator and file a missing person report within 24 hours. See LIC9099 on 10/07/2022 for more information.

A deficiency was cited for California Code of Regulations, Title 22.

This report was reviewed with Administrator, Juan Cooper and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/07/2022 12:37 PM - It Cannot Be Edited


Created By: Christine Dolores On 10/07/2022 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: NUEVA VISTA
FACILITY NUMBER: 435201796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2022
Section Cited
CCR
80061(b)(1)(E)

1
2
3
4
5
6
7
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
1
2
3
4
5
6
7
Licensee and Administrator will review section 80061 and send a statement of understanding of the section to LPA via email by POC due date.
8
9
10
11
12
13
14
Based on record review and interview, the facility did not ensure to report R1's AWOL to the Department which poses an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2