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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202728
Report Date: 03/13/2024
Date Signed: 03/14/2024 12:48:49 PM

Document Has Been Signed on 03/14/2024 12:48 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:SYCAMORE HOMEFACILITY NUMBER:
435202728
ADMINISTRATOR:NOEL HUANTEFACILITY TYPE:
737
ADDRESS:15160 SYCAMORE AVETELEPHONE:
(408) 915-5970
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 4CENSUS: 4DATE:
03/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Noel HuanteTIME COMPLETED:
12:00 PM
NARRATIVE
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On 03/12/2024 at approximately 1:45 p.m. Licensing Program Analyst (LPA) attempted to deliver findings for the complaint received on 12/12/2023. LPA observed that the facility was under construction and no resident or staff were present during the time of visit.

LPA was greeted by the 3 floor installers. LPA tried to communicate with the workers on site. Due to language barrier LPA was not able to get a lot information from the workers.

On 3/12/2024 at approximately 2PM; LPA contacted administrator (ADM) Noel Huante. ADM confirmed that the residents and staff relocated temporarily in Watsonville since 3/10/24 while the facility is undergoing floor replacement.

ADM stated all responsible parties, family of the residents and regional center is aware of the floor renovation for the facility. ADM stated that they did not inform CCL and was not aware that they are required to do so.

During today's visit, LPA informed ADM that it is the duty and responsibility of the ADM/Licensee to notify and inform Community Care Licensing (CCL) about any such temporary relocation and disruption of their daily activity and fulfill all CCL requirements prior to planned relocation such as but not limited to date of relocation, length of time of construction/renovation.

During today's visit, a citation was issued based on CCR Title 22, and a technical assistance was provided to ADM. An exit interview was conducted with ADM Noel Huante and a signed copy of this report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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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Document Has Been Signed on 03/14/2024 12:48 PM - It Cannot Be Edited


Created By: Maria Partoza On 03/13/2024 at 08:42 AM
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: SYCAMORE HOME
FACILITY NUMBER: 435202728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2024
Section Cited
CCR
80022(j)

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80022 (j) Any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval and shall be reported as specified in Section 80061. This requirement was not met as evidenced by;
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ADM will inform and notify CCL of future plans of temporary relocations. ADM stated a plan of action for future events such as the one cited today will be submitted to CCL.
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Based on interview and observation, the administrator did not notify and inform CCL of the temporary relocation and disruption of the daily activity & fulfill all CCL requirements prior to relocation, such as but not limited to the date and length of construction. This poses a health and safety risk to person in care.
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024


LIC809 (FAS) - (06/04)
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