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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202923
Report Date: 06/05/2024
Date Signed: 06/05/2024 12:53:46 PM

Document Has Been Signed on 06/05/2024 12:53 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:
435202923
ADMINISTRATOR/
DIRECTOR:		CISNA, DEREKFACILITY TYPE:
772
ADDRESS:14210 LESLEY LANETELEPHONE:
(949) 274-3632
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 6CENSUS: 0DATE:
06/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Derek Cisna & Danielle Morgan TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 6/5/2024 at 9:44 a.m. Licensing Program manager (LPM) Romeo Manzano and Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an announced pre-licensing inspection and met with Derek Cisna President and Danielle Morgan Operations in Compliance Specialist.

The facility is a social rehabilitation facility (SRF) for short term stay. The facility fire clearance is approved for 6 ambulatory clients and able to cognitively respond to emergency such as fire. At the time of inspection there are no clients observed.

At 9:55 a.m. LPM, LPA with applicants toured the facility inside and outside. The facility has a clinical office that is off limits to clients separated from the main building and under the ADU is a garage that will remain locked and secure at all times, and has been converted to a storage area and off limits to clients.

During inspection the facility has a swimming pool that is fenced in, locked with approximate height of about 5 feet, however, the fence surrounding the pool is made of plastic mesh and one inch in diameter posts that are drilled into the ground. When inspected for safety, the mesh can be cut with a sharp object and when tested for sturdiness and when force is applied it will cause the fence to bend, a pool bar was observed that is currently under construction, and as stated by the applicants, the pool bar will be used as a storage not accessible to clients.

During the tour of the front driveway, side parking, and a separate garage, the applicants stated that the garage is not accessible to clients and the open pavement side will be fenced in. The courtyard has a putting green and a half basketball court that can be used by clients as part of their activity. Applicants stated the garage is not included in the lease agreement. The exterior walkways are free from obstructions.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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: 435202923
VISIT DATE: 06/05/2024
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LPM, LPA with applicant toured the inside of the facility and inspected the entry way, office, 3 bathrooms, 4 client bedrooms, kitchen, medical office, dining, and living room. 2 out of 4 resident bedroom is shared, 2 out of 4 bedrooms are private. The facility has 4 designated exit routes per LIC 610D (emergency and disaster plan), front door, side door (left side of the house), kitchen, and staff office (back right side). The exit is free from obstruction. The facility has carbon monoxide and smoke alarm detectors combination and is centrally wired that are strategically placed throughout the building. The 2nd floor of the main building is utilized as a group room, the balcony will not be accessible to clients unless accompanied by a staff.

The facility fire extinguishers are placed strategically in the main area, clinical office and group room. The fire extinguishers were serviced on 8/23/2023, 12/11/2023.

First Aid cabinets were observed mounted on the wall and are accessible to staff throughout the facility and contains first aid supplies, with manual, tweezers and scissor. LPA suggested to remove sharp objects from first aid kit and pain medications from the first aid kit.

The laundry area is located in the hallway not easily accessible to clients. The laundry detergents, cleaning supplies and other toxic are locked and can only be accessed by staff.

Medical office was observed to be secured and locked. The medical office was observed to have the following items such as working telephone, locked medication cabinet and medication refrigerator, sharps bin, a portable first aid kit, evacuation map, flight lights, and emergency disaster plan.

LPA observed the kitchen is equipped with kitchen appliances such as but not limited to refrigerator, dishwasher, stove with oven. The kitchen has plates, bowls, cups, drinking glasses and utensils. Knives are in a locked cabinet and are not easily accessible to clients in care.

The activity/game room has access to a bathroom with two person bathtub approximately 3.5 feet deep and 5 feet wide. Applicant stated that the bathtub will not be used by clients. LPA suggested to turn off the water supply to the bathtub for safety concerns. page 2 of 3
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

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

DATE: 06/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 435202923
VISIT DATE: 06/05/2024
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4 Out of 4 resident bedrooms have adequate lighting, bed frames with mattress, linens, lamps, night stands, drawer dresser storage and closet space that is sufficient to store clients’ personal belongings.

3 Out of 3 bathrooms hot water temperature measured from 113.7 to 120 degree Fahrenheit. Room temperature is at 73 degree F. The facility has a centralized air-conditioning system.

Applicant stated during the tour that the property facing the house to your right is occupied by the property owner and a dividing fence will be extended to close off the access to the owner's commercial storage area.

During the inspection inside and out the following areas needs to be addressed for safety of clients.

1. Pool area - applicant has to submit a plan to address the sturdiness of the fence surrounding the pool.
2. Driveway - applicant has to submit a plan to address the division between the owner's commercial storage area and the facility.
3. Balcony on the 2nd floor - group activity room - applicant has to submit a plan to address the safety when the balcony is in use by the client (balcony is drop is approximately 25 to 30 feet)
4. Courtyard area - applicant has to submit a plan to address the open paved area on the left side of the garage that has access to the back hill of the property.
5. Pool bar area - applicant has to submit a plan to address the construction of the pool bar that it will be used as a storage.

Applicant will contact LPA when corrections have been made to the above list of concerns and to schedule the next inspection with LPA.

Component III was presented to the applicant. This report was reviewed with applicant Derek Cisna and Danielle Moragan copy of the report was provided.

end of report


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

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

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