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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200566
Report Date: 02/09/2023
Date Signed: 02/09/2023 03:39:39 PM


Document Has Been Signed on 02/09/2023 03:39 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:MAPLE HOUSE, THEFACILITY NUMBER:
445200566
ADMINISTRATOR:CHEN, HONG-GENFACILITY TYPE:
740
ADDRESS:410 PENNSYLVANIA AVENUETELEPHONE:
(831) 423-6347
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:22CENSUS: DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Anne RoxasTIME COMPLETED:
03:42 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 Ryker Heberle (LPA) conducted an unannounced annual inspection on 02/09/2023 at 02:01pmm. LPA met with facility Administrator Anne Roxas (Admin).

LPA toured the facility, including living room, kitchen, dining room, laundry room, Office, 7 bedrooms, 5 bathrooms, and back yard. Staff members were observed not to be wearing masks upon LPA entrance into the facility, but donned masks once LPA identified himself. Admin confirmed that all staff and residents have been vaccinated.

Facility infectious control plan has already been submitted. 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. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in May 2022. Smoke/carbon monoxide detectors tested and observed to be operational.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All shared restrooms stocked with paper towels. Water temperature observed to be 119.7 *F. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. This report was reviewed with Administrator Anne Roxas 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: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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 1