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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440708908
Report Date: 02/26/2024
Date Signed: 02/26/2024 03:48:24 PM


Document Has Been Signed on 02/26/2024 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:WESLEY HOUSE IIFACILITY NUMBER:
440708908
ADMINISTRATOR:LEON, JANETFACILITY TYPE:
740
ADDRESS:121 LA SELVA DRIVETELEPHONE:
(831) 685-0646
CITY:LA SELVA BEACHSTATE: CAZIP CODE:
95076
CAPACITY:6CENSUS: 2DATE:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Janet LeonTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Janet Leon.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed the facility kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. LPA Marrufo toured 3 out of 3 resident bedrooms and observed each bedroom to have available bedding and clothing storage areas and functioning lights. LPA Marrufo tested the smoke and carbon monoxide detectors and they functioned properly when tested.

LPA Marrufo toured 2 out of 2 resident bathrooms and observed each bathroom had water temperature at 115 F. Each bathroom had available soap and paper towels and working lights.

LPA Marrufo toured the outside area and observed the exits to be clear of obstructions.

LPA Marrufo toured the resident records and Centrally Stored Medication Logs and found them to be complete. LPA Marrufo reviewed staff records and found them to be complete.

No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Janet Leon and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
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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