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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:49:52 AM


Document Has Been Signed on 02/10/2023 11:49 AM - 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:LOMA CLARA SENIOR LIVINGFACILITY NUMBER:
435202665
ADMINISTRATOR:JAIRUS CABUENAFACILITY TYPE:
740
ADDRESS:16515 BUTTERFIELD BLVDTELEPHONE:
(669) 258-3500
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:89CENSUS: DATE:
02/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Jett CabuenaTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Executive Director, Jairus "Jett" Cabuena.

The purpose of the visit was to follow-up with a self reported SOC-341 that our Department received regarding inappropriate behavior staff had with resident(s) in care.

During visit, LPA toured the Generations section with ED, also known as memory care. Residents were observed participating in activities with the supervision of multiple staff.

LPA interviewed 4 staff (S1 - S4) members in Generations.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with, Executive Director, Jairus "Jett" Cabuena and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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