<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
440703228
Report Date:
09/10/2024
Date Signed:
09/10/2024 10:45:17 AM
Document Has Been Signed on
09/10/2024 10:45 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 HOME
FACILITY NUMBER:
440703228
ADMINISTRATOR:
MARSHA BELLEZA
FACILITY TYPE:
740
ADDRESS:
813 HANOVER STREET
TELEPHONE:
(831) 426-0618
CITY:
SANTA CRUZ
STATE:
CA
ZIP CODE:
95062
CAPACITY:
15
CENSUS:
10
DATE:
09/10/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:35 AM
MET WITH:
Administrator, Marsha Belleza
TIME COMPLETED:
10:50 AM
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 Analysts (LPAs) Marcella Tarin and Christine Dolores arrived unannounced to conduct a case management-other visit. LPAs met with Administrator Marsha Belleza.
The purpose of the visit was to amend deficiencies from visit date 8/27/2024. LIC809Ds reviewed with Administrator and a copy of the amended deficiencies were provided during visit.
Administrator was advised to submit the plan of corrections for deficiencies section cited 1569.695(c) and 87506(a).
No deficiencies were cited today per California Code of Regulations Title 22. This report was reviewed with Administrator Marsha Belleza and a copy of the report was provided.
SUPERVISOR'S NAME:
Jin Jackie
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Marcella Tarin
TELEPHONE:
(714) 328-5152
LICENSING EVALUATOR SIGNATURE:
DATE:
09/10/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/10/2024
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