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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440700458
Report Date: 09/02/2020
Date Signed: 09/02/2020 10:42:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MYSTIC OAKSFACILITY NUMBER:
440700458
ADMINISTRATOR:MILLER, LUCILLEFACILITY TYPE:
740
ADDRESS:163 GLENWOOD DRIVETELEPHONE:
(831) 438-2729
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:6CENSUS: 2DATE:
09/02/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Roger Roesner, AdministratorTIME COMPLETED:
10:50 AM
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Licensing Program Analysts (LPAs) Jackie Jin and Ryker Heberle conducted an unannounced Case Management visit. This case management visit is to conduct a health and safety check and ensure the facility is adhering to health protocols. LPA met with Roger Roesner, Administrator.

During today's visit LPA toured the facility inside and outside including the resident bedrooms, bathrooms, living room and kitchen. Bedrooms and living room were observed with furnishings that are in good repair. Bathrooms were observed clean, and with hygiene supplies and toiletries. The facility has lighting in the bedrooms and common areas. Residents have a 30 days supply of medications. First aid kit was complete. 2 days worth of perishables and 7 days worth of nonperishable were observed. Two weeks of emergency food supply was observed. Hot water temperature was maintained at 111.7 degrees Fahrenheit. Facility temperature was maintained at 62 degrees Fahrenheit.

Residents were observed and interviewed. Residents were clean, groomed, and with no serious injuries.

Facility is still following health protocols during this pandemic.

No deficiencies cited during today's visit.

This report was reviewed with Roger Roesner, Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2020
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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