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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440707795
Report Date: 04/11/2024
Date Signed: 04/11/2024 10:29:24 AM

Document Has Been Signed on 04/11/2024 10:29 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:ROLLING RIDGE R.C.H.FACILITY NUMBER:
440707795
ADMINISTRATOR/
DIRECTOR:		CARLONE, MICHAELFACILITY TYPE:
735
ADDRESS:751 LARKIN VALLEY ROADTELEPHONE:
(831) 475-0888
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 12CENSUS: 8DATE:
04/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Andreas FernandezTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Andreas Fernandez.

During visit, LPA Marrufo requested that the following documents be submitted to CCL within 24 hours for residents R1-R5:

Most current Physician's Report, Admission Agreement, most current IPP Assessment (if applicable), Incident Reports from the last 6 months, and Case Notes.

LPA Marrufo also requests the following documents be submitted to CCL within 24 hours for staff S1-S5:

LIC501, training records, Staff write-ups, and Employment Application.

LPA requests the following facility records be submitted to CCL within 24 hours:

Current Administrator Certificate, Actual Staff Schedule from March and April 2024, and Resident Roster.

LPA conducted a wellness check with the three residents who were present during visit.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Andreas Fernandez and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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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