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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202907
Report Date: 05/06/2024
Date Signed: 05/07/2024 08:31:18 AM

Document Has Been Signed on 05/07/2024 08:31 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/
DIRECTOR:		CISNA, DEREKFACILITY TYPE:
772
ADDRESS:14865 MARIE COURTTELEPHONE:
(949) 836-6793
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 6CENSUS: 5DATE:
05/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Joshua Fane - Program DirectorTIME VISIT/
INSPECTION COMPLETED:
02:27 PM
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On 5/6/2024 Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management visit. LPA stated the purpose of the visit and met with Program Director (PD) Joshua Fane.

The facility has a current census of 5 clients and 7 staff were present at the facility during today's visit.
4 out of 5 were in the facility. 1 out of 5 clients was in the bedroom resting, 4 out of 5 clients were in the living room doing individual activities.

At 12:20 pm, LPA and PD toured the facility inside and outside, and observed the following. LPA inspected the kitchen, dining room, 4 clients rooms, living room, bathroom, garage and staff room, laundry room and coffee area. LPA observed that laundry soaps, cleaning supplies, toxic and knives are kept in a locked cabinet. PM stated that the chef brings his/her own kitchen knives and is not kept in the facility. LPA observed medications are locked and is not easily accessible to clients. PD stated that clients can administer their own medication with supervision from a staff. The kitchen is observe to be sanitary and organized, the garage was observed clean and organized, the program schedule is posted on the wall. The coffee area is sanitary and organized. LPA observed hallways are free of debris and is free from obstructions.

LPA inspected the outdoor perimeter/exterior of the facility, including but not limited to the deck area, the pool area, backyard and parking lot. LPA observed a gate is used access the parking lot. LPA observed a three car garage next to the parking lot. PD stated that the garage is not accessible to staff and is used by the landlord as a storage. LPA and PD inspected two outdoor offices used by case manager and therapist and found them to be well maintained and organized.

LPA observed sliding doors going to the back of the facility is free from any obstructions. The back/grass area are maintained and free from obstructions. PD stated that the outdoor kitchen is not used at this time.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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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: 05/06/2024
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LPA observed that the pool is fenced in with a metal wire mesh. The pool gate is locked and is not easily accessible to clients in care. The gate used by staff to enter the facility from parking area does not have a lock and is does not have an alarm to notify staff if any one is coming in and out of the facility.

The back walkway is free from obstruction. LPA observed soil was disturbed behind the white fence. PD stated that Public Health came and tested the soil. LPA observed the soil disturbance is approximately 200 feet away from the building were clients reside.

LPA requested the following documents from PD; staff roster, client roster, LIC 308 and the LIC 500.

No deficiencies were cited as of today's visit. An exit interview was conducted with Project Director (PD) Joshua Fane and a copy of this report was provided.

END OF REPORT
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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