<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440703228
Report Date: 08/09/2022
Date Signed: 08/09/2022 01:31:18 PM


Document Has Been Signed on 08/09/2022 01:31 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:HANOVER GUEST HOMEFACILITY NUMBER:
440703228
ADMINISTRATOR:MARSHA BELLEZAFACILITY TYPE:
740
ADDRESS:813 HANOVER STREETTELEPHONE:
(831) 426-0618
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:15CENSUS: DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Marsha BellezaTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/09/2022. LPA met with facility Administrator Marsha Belleza (Admin).

LPA toured the facility, including front office, laundry room, storage room, 5 bathrooms, 8 bedrooms, garage, living room, and back yard. Staff members were observed not to be wearing masks upon LPA arrival, staff had masks immediately accessible that were donned upon LPA request. Admin confirmed that all staff and residents have been vaccinated. Facility infectious control plan has not yet been submitted to licensing.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. 30 days worth of PPE was observed.

Facility observed to have designated entry point. Staff took LPA's temperature, but did not screen for symptoms. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. Staff has completed N95 fit testing.

Facility fire extinguishers were observed to have been serviced in January of 2022. Facility water temperature observed to be 108.3*F. Residents were observed eating in the dining room. LPA observed smoke detectors and a carbon monoxide detector.

No deficiencies cited during today's visit. This report was reviewed with Administrator Marsha Belleza and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1