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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440700458
Report Date: 05/06/2021
Date Signed: 05/06/2021 04:18:22 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:
05/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Roger RoesnerTIME COMPLETED:
04:18 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an on-site case management visit with Administrator Roger Roesner (Admin) to conduct a closing inspection.

LPA toured all rooms in the facility, including bedrooms, kitchen, storage closets, bathrooms, backyard, living room, greenhouse, and medicine room. All resident personal belongings and medications noted to be removed from facility. No residents were seen during the visit.

Admin surrendered licence to LPA and provided written statement of relationship with closure announcement on behalf of licensee to LPA.

No deficiencies noted during visit.

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

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
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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