<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440708773
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:27:38 PM


Document Has Been Signed on 05/10/2024 03:27 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 OAKSFACILITY NUMBER:
440708773
ADMINISTRATOR:KATHERINE WILLFACILITY TYPE:
740
ADDRESS:3400 PAUL SWEET ROADTELEPHONE:
(831) 462-6257
CITY:SANTA CRUZSTATE: CAZIP CODE:
95065
CAPACITY:142CENSUS: 45DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Front Desk Manager, Brenda Barber TIME COMPLETED:
03:30 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) Simi Rai conducted an unannounced Required 1 Year visit and met with Front Desk Manager, Brenda Barber. The facility currently has a COVID-19 outbreak and residents are in isolation.
During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. The temperature of 4 refrigerators were observed at 35-40 degree Fahrenheit (F), and the temperature of freezer was -3-0 degree F. LPA observed additional food supply areas and secured areas for cleaning supplies. There were posters above the kitchen sinks stating the water temperature may be above 120 degrees F.
LPA Rai toured 3 resident bedrooms. The water temperature in the bathroom sinks ranged from 111.7 degrees F - 117.1 degrees F. Resident apartment bathrooms were observed with grab bars and non-skid pads. The window and patio door screens were clean and in good repair. The room temperatures were between 68 degrees F - 71 degrees F. Fire extinguisher was observed and inspected on 9/18/2023. Facility fire alarm was inspected on 9/28/2023 and 12/5/2023. The last disaster drill was conducted on 1/5/2024. Facility staff could not produce disaster drills conducted after 1/5/2024. Carbon monoxide detectors are located in the boiler room and facility kitchen.
LPA Rai reviewed facility records for 3 staff and 3 residents. 3 Out of 3 staff files did not contain job application form or Personnel Record form. LPA Rai reviewed resident medications and central stored medication records. Medications rooms and medication carts were observed locked. The facility did not report 3 cases COVID-19 within 7 day window for reporting requirements.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC-809D. This report was reviewed with Front Desk Manager, Brenda Barber and a copy of this report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
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)
Page: 1 of 3


Document Has Been Signed on 05/10/2024 03:27 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
87412(a)

1
2
3
4
5
6
7
87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Manager stated to submit a written plan of action understanding regulation and will ensure staff files are complete by POC due date. Manager agreed and understood.
8
9
10
11
12
13
14
Based on record review and interview, 3 out of 3 staff files do not contain Application/Personnel Record which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
05/17/2024
Section Cited
CCR87211(a)(1)

1
2
3
4
5
6
7
87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.
1
2
3
4
5
6
7
Manager stated to submit a written plan of action understanding regulation and will ensure COVID-19 cases are reported to the Deparment in a timely manner by POC due date. Manager agreed and understood.
8
9
10
11
12
13
14
Based on record review and interview, 3 COVID-19 cases were not reported within the 7 day window which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/10/2024 03:27 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
HSC
1569.695(c)

1
2
3
4
5
6
7
1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Manager stated to submit a written plan of action understanding regulation and will ensure disaster drills are conducted at least quarterly by POC due date. Manager agreed and understood.
8
9
10
11
12
13
14
Based on interview and record reivew, facility staff were not able to produce diaster drills conducted after 1/5/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3