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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440708773
Report Date: 06/30/2022
Date Signed: 06/30/2022 02:26:48 PM


Document Has Been Signed on 06/30/2022 02:26 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:DOMINICAN OAKSFACILITY NUMBER:
440708773
ADMINISTRATOR:KATHERINE WILLFACILITY TYPE:
740
ADDRESS:3400 PAUL SWEET ROADTELEPHONE:
(831) 462-6257
CITY:SANTA CRUZSTATE: CAZIP CODE:
95065
CAPACITY:142CENSUS: 52DATE:
06/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Amy SaulnierTIME COMPLETED:
02:29 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 06/30/2022 at 01:01pm. LPA met with facility Administrator Amy Saulnier (Admin). LPA toured the facility, including front office, medicine room, 10 resident apartments, 2 dining rooms, kitchen, activities room, and 2 public bathrooms.

All staff members observed to be wearing masks. Admin confirmed that all residents and staff have been vaccinated. Infectious control plan has been completed and is awaiting approval.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility water temperature observed to be 116.7*F in resident apartments. Fire extinguisher noted to have received inspection in September 2021. Facility observed to have 2 days supply of perishable food and 1 weeks supply of non-perishable food. Facility signal alert systems were tested and staff responded in less than 2 minutes.

Facility noted to possess a 30-day supply of PPE. Facility observed to have designated entry point. Staff took LPA's temperature, and screened for symptoms. All restrooms observed to be stocked with paper towels and lidded trash cans. Hand washing signs observed in all bathrooms. Social distancing signs observed posted throughout facility in all public areas. Facility communal dining observed to be shut down in response to COVID positivities in independent living wing.

No deficiencies cited during today's visit. This report reviewed with Facility Administrator Amy Saulnier and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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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