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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440708122
Report Date: 05/10/2024
Date Signed: 05/10/2024 12:07:52 PM


Document Has Been Signed on 05/10/2024 12:07 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:RILLERA'S GUEST HOMEFACILITY NUMBER:
440708122
ADMINISTRATOR:RILLERA, ZOSIMAFACILITY TYPE:
740
ADDRESS:40 FLETCHER COURTTELEPHONE:
(831) 724-0985
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:6CENSUS: 5DATE:
05/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Clarence RilleraTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Clarence Rillera.

The purpose of the visit was to conduct a health and wellness check with resident R1, who was transferred to the facility on 04/30/2024 when R1's previous facility ceased operation.

During visit, LPA Marrufo observed and interviewed R1. LPA Marrufo observed R1's bedroom and observed R1's personal belongings in the bedroom.

LPA Marrufo observed R1's medications and reviewed R1's resident records.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Clarence Rillera and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
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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