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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200582
Report Date: 10/25/2021
Date Signed: 10/25/2021 12:18:34 PM

Document Has Been Signed on 10/25/2021 12:18 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:WRC-1FACILITY NUMBER:
445200582
ADMINISTRATOR:JAMES RUSSELLFACILITY TYPE:
735
ADDRESS:155 WILLOWBROOK DRIVETELEPHONE:
(831) 336-5196
CITY:BEN LOMONDSTATE: CAZIP CODE:
95005
CAPACITY: 34CENSUS: 33DATE:
10/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Lindsey PilkingtonTIME COMPLETED:
12:20 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit in response to the facility evacuation that occurred on 10/24/2021 due to flooding. LPA met with Lindsey Pilkington, Mental Health Support Services Manager (MHSS Manager).

Facility residents were evacuated to San Lorenzo High School, where they stayed the night in the multi-purpose room. Residents began repopulating the facility at approximately 10:00am on 10/25/2021. LPA visited the facility to ensure the safe repopulation of all residents.

During tour of the facility with MHSS Manager, LPA observed 29 out of 33 residents present at the facility. 1 resident had evacuated to his/her family's home, 2 residents are currently staying at other facilities, and 1 resident had left the facility immediately after repopulation. LPA confirmed with staff and residents that unseen resident had returned to the facility on the bus with other residents. All 33 residents have been accounted for.

LPA observed no damage to the facility as a result of flooding. Admin confirmed that the facility sustained no damage.

LPA requested and reviewed documentation from facility, including resident roster, disaster plan, relocation plan, flood plan, and power shut off plan.

No deficiencies cited during today's visit. This report was reviewed with Lindsey Pilkington, MHSS Manager and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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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