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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440708122
Report Date: 09/13/2024
Date Signed: 09/25/2024 11:50:26 AM

Document Has Been Signed on 09/25/2024 11:50 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:RILLERA'S GUEST HOMEFACILITY NUMBER:
440708122
ADMINISTRATOR/
DIRECTOR:		RILLERA, ZOSIMAFACILITY TYPE:
740
ADDRESS:40 FLETCHER COURTTELEPHONE:
(831) 724-0985
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 6CENSUS: 4DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Ellis PascualTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Ellis Pascual.

During visit, LPA toured the facility inside and out. LPA toured the facility kitchen and food storage areas and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the facility first aid kit and found it to be complete.

LPA toured three out of three resident rooms. Each room had functioning lights and available bedding and clothing storage areas. The smoke detectors in each room and in the hallway were tested and found to function properly. LPA toured two out of two facility bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in both bathroom sinks were 112 F.

LPA toured the outside area and found it to be clear of obstructions.

LPA reviewed 4 resident records and Centrally Stored Medication and Destruction Records and found them to be complete. LPA reviewed 3 staff records and found them to be complete.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Ellis Pascual and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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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