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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202907
Report Date: 08/29/2024
Date Signed: 08/29/2024 06:42:18 PM

Document Has Been Signed on 08/29/2024 06:42 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: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: 6DATE:
08/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:30 PM
MET WITH:Joshua Fane - Designated Program DirectorTIME VISIT/
INSPECTION COMPLETED:
06:41 PM
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8/29/2024 Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management visit on the status of the facility. LPA was greeted by a staff and staff called Designated Program Director (DPD) Joshua Fane. DPD arrived at the facility within 6 minutes.

LPA toured the facility with DPD and staff, including but not limited to the kitchen, dining, residents bedrooms, bathrooms, group room, office, garage, the exterior perimeter, driveway, detached garage, fenced field at the end of the property.

LPA observed that the facility is sanitary, organized and maintained inside and outside. The pool area is fenced in and is not accessible to residents. There are two clinical offices at the side of the building that is utilized by licensed therapists and case managers. The driveway is free from obstruction. The backyard is maintained and free from debris. The back walkway is free from obstruction.

LPA observed soil was disturbed in the fenced field, DPD stated that Public Health came and tested the soil in April 2024. LPA observed the soil disturbance is approximately 200 feet away from the building were clients reside. The detached garage is not used as a living space but a storage used by the landlord.

No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Designated Program Director Joshua Fane and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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