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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202923
Report Date: 07/16/2024
Date Signed: 07/16/2024 10:22:06 AM

Document Has Been Signed on 07/16/2024 10:22 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:
435202923
ADMINISTRATOR/
DIRECTOR:		CISNA, DEREKFACILITY TYPE:
772
ADDRESS:14210 LESLEY LANETELEPHONE:
(949) 274-3632
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 6CENSUS: 0DATE:
07/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Josh Fane and Shayla LinnTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 7/16/2024 at 8:55 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted a second announced pre-licensing inspection and met with Josh Fane Operations Manager (OM) and Shayla Linn Operations and Compliance Specialist (OCS).

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 9:00 a.m. LPA with applicants toured the facility inside and outside to inspect the corrections required prior to approval of the license. The following were discussed during the previous pre-licensing visit on 6/5/2024.
and the area of concerns were addressed by the applicant.

1. Pool area - have been addressed, applicant submitted photos and a physical inspection was conducted. LPA observed that the pool fence was properly installed. To address other concern regarding the pool's safety and security; applicant stated the pool area will be monitored by surveillance camera and clients who wishes to use the pool will need a clearance from the client's mental health provider. Applicant stated that clients will be supervised when using the pool.

2. Driveway (east side of the property) - applicant has submitted photos and was physically inspected by LPA. LPA observed that the fence was extended closing off the access to the owner's commercial storage area.

3. Balcony on the 2nd floor - group activity room - applicant has addressed the safety of the balcony by locking the sliding door going to the balcony. Applicant stated the balcony sliding door will remain locked and will not be used by the client.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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: 07/16/2024
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4. Courtyard area - applicant submitted photos and a physical inspection was conducted during today's visit. LPA observed that applicant built a fence to secure the open paved area on the left side of the garage.

5. Pool bar area - applicant submitted a photo and a physical inspection was conducted during today's visit. LPA observed the area to be free of debris and no bathroom or shower in the pool bar area was observed.

Other issues were addressed during today's visit such as the first aid kits, and the water supply for the deep bathtub located at the activity/game room.

No other corrections or deficiencies were observed during today's visit, corrections has been cleared, pre-licensing is now complete.

An exit interview was conducted with Josh Fane Office Manager and Shayla Linn, Operations and Compliance Specialist.

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end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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