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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440703228
Report Date: 07/18/2024
Date Signed: 07/18/2024 10:13:52 AM


Document Has Been Signed on 07/18/2024 10:13 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: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: 11DATE:
07/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator Marsha BellezaTIME COMPLETED:
10:20 AM
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Licensing Program Analyst Manuel Monter conducted an unannounced case management to amend a case management deficiency page. The LIC809-D was issued on May 22, 2024. LPA observed 3 staff and 10 residents.

LPA met with Administrator Marsha Belleza. LPA explained the purpose of the visit.

No deficiencies cited during todays visit. This Report was reviewed with Administrator Marsha Belleza. A signed copy was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
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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