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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440708773
Report Date: 01/11/2024
Date Signed: 01/12/2024 08:07:52 AM


Document Has Been Signed on 01/12/2024 08:07 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
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: 47DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Amy SaulnierTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Administrator (ADM) Amy Saulnier. LPA toured the facility inside and out with ADM including library, activity rooms, dinning rooms, kitchen, laundry rooms, public restrooms and resident apartments. ADM stated the facility has 47 residents in assisted living unit and 153 residents in independent living unit. License, Administrator Certificate, and personal right posters were observed posted at entrance.

5 resident files and 5 staff files were reviewed. 2 out of 5 resident files were incomplete.

Room temperature was measured at 69 degree F, and hot water temperature was measured at 117 degree F. The temperature of refrigerator was 40 degree F, and the temperature of freezer was 0 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Fire extinguishers were serviced on 09/18/2023. The facility was equipped with fire alarm system. Carbon monoxide detector was only observed at kitchen. Fire alarm and smoke detectors were tested by ADM, and were working fine.

Medications rooms and medication carts were observed locked. Two resident rooms emergency signal alert systems were tested and staff responded in 2 minutes. Resident apartment bathrooms were observed with grab bars and non-skid pads. Oxygen use poster was observed posted on the resident apartment door for oxygen administration resident.

LPA toured the back yard of the facility. No obstruction was observed blocking the walkways. ADM stated the last time for the emergency and fire drill was conducted on10/27/2023.

Exit interview was conducted with ADM. Deficiencies noted for today's inspections. LIC809-D was attached. The report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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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Document Has Been Signed on 01/12/2024 08:07 AM - 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: DOMINICAN OAKS
FACILITY NUMBER: 440708773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record reviewed, the Administrator did not comply with the section cited above in that 2 out of 5 resident files reviewed were incomplete which poses/posed a potential health, safety isk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date to complete resident files.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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