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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440700458
Report Date: 09/11/2020
Date Signed: 09/11/2020 02:15:40 PM

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: DATE:
09/11/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Roger RoesnerTIME COMPLETED:
02:15 PM
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Licensing Program Manager (LPM) Sarah Yip, Licensing Program Analyst (LPA) Ryker Heberle, and Licensing Program Analyst (LPA) Jackie Jin met with Administrator Roger Roesner (Admin) for an office visit in the San Jose CCL office. The purpose of the visit was to discuss the facility emergency plan and the association of licensee Lucille Miller with the facility.

Admin indicated that he intends to take over as licensee of the facility. LPM advised that Admin should re-associate Lucille Miller as the licensee and apply for a change in ownership later. Admin completed form LIC 9162 given by LPM.

LPM gave Admin LIC 200 to begin the application process for change of ownership. Central application bureau contact info is as follows:

Address: 744 P Street, 8-3-91, Sacramento, CA, 95814
Phone #s: (916) 657-2600 & (916) 651-7844
Main Phone for CCLD San Jose: (408) 324-2112

LPM reviewed PINs 18-18-ASC with Admin regarding emergency evacuation procedures. A copy of the floor sketch was reviewed by Admin as accurate. The contact information of the facility/admin was verified with Admin. A copy of PIN 18-18-ASC, 20-23-CCLD and 20-28-ASC were given to Admin. LPM advised Admin to contact both LPA Ryker Heberle and CCLD Main Line in case of future emergency.

This report was reviewed with Roger Roesner and a copy of this report provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020
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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