440708773-5-27-2026-26-AS-MTAN-DUGUR7-20260527154817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 440708773
Report Date: 05/27/2026
Date Signed: 05/27/2026 03:48:36 PM

Document Has Been Signed on 05/27/2026 03:48 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:	DOMINICAN OAKS		FACILITY NUMBER:	440708773
ADMINISTRATOR/ DIRECTOR:	SAULNIER, AMY		FACILITY TYPE:	740
ADDRESS:	3400 PAUL SWEET ROAD		TELEPHONE:	(831) 462-6257
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95065
CAPACITY: 142		CENSUS: 42	DATE:	05/27/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Administrator (ADM) Amy Saulnier		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Amy Saulnier. ADM states the facility has 42 clients. LPA toured the interior of the facility with the ADM. LPA toured the first floor (Assisted Living) in wings C and D (as shown on the facility sketch) with ADM to include but not limited to the kitchen, resident rooms, dining area, and resident activity areas. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area 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 refrigerator temperature at 34 F and Freezer at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. LPA observed the facility to be clean, safe, sanitary and in good repair. The smoke detectors were last inspected by a third party vendor on 2/3/2026 and passed inspection. Fire extinguishers were last serviced on 09/25/25. The facility emergency drill log was reviewed. The facility's last drill was conducted on 3/4/2026. Page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: DOMINICAN OAKS	FACILITY NUMBER: 440708773
	VISIT DATE: 05/27/2026

NARRATIVE

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LPA toured 10 resident rooms. All 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 10 resident bathrooms. All 10 resident bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature in 10 resident bathrooms with a range of 108.1 F to 118.4 F.

LPA reviewed 5 residents records.

LPA reviewed 5 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s) with ADM and Staff S2 and S3. During review, LPA observed R1 had one medication not listed on the CSDMR. Upon further review, S2 and S3 were unable to find a physician's order for the medication. S2 and S3 found that the medication belonged to R1's spouse (also a resident), who had a physician's order for the medication. S2 and S3 stated the medication was not given to R1. S2 states the medication was not documented on R1's spouse's CSMDR when received in December 2025. A deficiency is being issued.

LPA reviewed 5 staff records.

A deficiency is being cited during today's visit per California Code of Regulations Title 22. See LIC809D. An exit interview was conducted with Administrator (ADM) Amy Saulnier and a signed copy of this report and appeals rights were provided.

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END OF REPORT

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/27/2026 03:48 PM - It Cannot Be Edited

Created By: Marcella Tarin On 05/27/2026 at 03:25 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: DOMINICAN OAKS	FACILITY NUMBER: 440708773
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(6)

87465(6) Incidental (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review and interview, the licensee did not comply with the section cited above. During review of R1's medications, LPA observed R1 to have a medication not listed on the CSMDR. The medication belonged to R1's spouse, and the medication was not recorded on the CSMDR which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2026
	Plan of Correction
1 2 3 4	ADM will submit a plan of correction on how she will ensure staff are documenting medications appropriately for each resident. ADM to submit POC to CCL by POC due date of 6/3/2026

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:

	Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC809 (FAS) - (06/04)

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