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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440707795
Report Date: 03/09/2022
Date Signed: 03/10/2022 08:09:57 AM

Document Has Been Signed on 03/10/2022 08:09 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
CCLD Regional Office,
, CA
FACILITY NAME:ROLLING RIDGE R.C.H.FACILITY NUMBER:
440707795
ADMINISTRATOR:CARLONE, MICHAELFACILITY TYPE:
735
ADDRESS:751 LARKIN VALLEY ROADTELEPHONE:
(831) 475-0888
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 12CENSUS: 9DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Casey ClarkTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Casey Clark Administrator.

LPA toured the facility inside and out. Facility has a designated isolation room with exterior door exit. All fire exit routes were free and clear of obstructions. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the kitchen.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products and hand Washing signs posted. Hand sanitizer available to visitors and residents. LPA observed supply of Personal Protective Equipment (PPE) and Isolation Cart. COVID 19 signs posted included Visitor Policy, Face Coverings Required For Entry, Cover Your Face, Droplet Precautions, How Can I Protect Myself, Limit Family Gatherings, Self Monitor and Practice, Tips for Reducing COVID 19 Indoors, Lets Keep Our Facility Clean, Limit Family Gatherings, COVID 19 Response and Are You Feeling Ill.
LPA reviewed the facility policies and procedures to include screening, visitation, masking, isolation and disinfecting,

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Casey Clark Administrator and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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