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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202907
Report Date: 08/22/2023
Date Signed: 08/22/2023 10:29:34 AM

Document Has Been Signed on 08/22/2023 10:29 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:CALIFORNIA MENTAL HEALTH LLCFACILITY NUMBER:
435202907
ADMINISTRATOR:CISNA, DEREKFACILITY TYPE:
772
ADDRESS:14865 MARIE COURTTELEPHONE:
(949) 836-6793
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 8CENSUS: 0DATE:
08/22/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:DEREK CISNATIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived announced to conduct the facility's pre-licensing inspection. LPA met with Administrator Derek Cisna, Program Director James Blumenschein, Compliance Operations Manager Danielle Morgan, Compliance Laura Hagan.

The facility's fire clearance is approved for 8 ambulatory clients. There are no clients on-site.

During visit, LPA toured the facility with Danielle to include the entry, office, group room, bathrooms, client bedrooms, backyard, kitchen, garage, and living room. All exit routes are free and clear of obstruction. The facility has operable carbon monoxide detectors / smoke alarms throughout the building. Fire extinguishers serviced on 05/16/2023. First Aid Kits observed throughout the facility.

Facility's entrance contains a sign-in sheet, schedule, house rules, medication time, visitor policy, licensing complaint poster, personal rights, resident counsel, and COVID-19 related poster.

Office room observed secured with locks on the doors. The office room contains an operable telephone, locked medication cabinet, locked medication refrigerator, sharps bin, complete first aid kit, evacuation map, flight lights, and the emergency disaster plans. LPA observed the facility has a Personal Protective Equipment (PPE) cart to include supplies such as gowns, gloves, masks, shields and hand sanitizer.

4 out of 4 bedrooms contain adequate lighting, beds, clean linens, night stands, lamp shades, dressers and closet space.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: CALIFORNIA MENTAL HEALTH LLC
FACILITY NUMBER: 435202907
VISIT DATE: 08/22/2023
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Bathrooms contained hygiene products, paper supplies, and hand washing signs. Hot water temperature maintained at 109 - 110 degrees Fahrenheit.

The facility's swimming pool was observed inaccessible and surrounded by a locked fence. The backyard contains 2 storage units that is furnished with lights, a desk and chairs and will be used as private spaces for clients appointments. The facility has a designated smoking area. The backyard is furnished with tables, chairs, and shade.

The kitchen is equipped with appliances, clean plates, bowls, cups, utensils, and non-perishable foods.

The garage contains locked storage cabinets that contains disinfectants, sharps, emergency food supplies, non-perishable foods, linens, and hygiene products. The garage observed with activity and gym equipment.

COMP III not completed during visit due to technical difficulties. LPA will collaborate with the Administrator for a follow-up visit.

No issues noted during this pre-licensing inspection.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Administrator Derek Cisna, Program Director James Blumenschein, Compliance Operations Manager Danielle Morgan, Compliance Laura Hagan and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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