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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200582
Report Date: 02/24/2022
Date Signed: 02/24/2022 11:19:58 AM

Document Has Been Signed on 02/24/2022 11:19 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:WRC-1FACILITY NUMBER:
445200582
ADMINISTRATOR:MEGAN C. MILLERFACILITY TYPE:
735
ADDRESS:155 WILLOWBROOK DRIVETELEPHONE:
(831) 336-5196
CITY:BEN LOMONDSTATE: CAZIP CODE:
95005
CAPACITY: 34CENSUS: DATE:
02/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Megan MillerTIME COMPLETED:
11:22 AM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced Case Management visit and met with facility administrator Megan Miller (Admin). During visit, LPA spoke with Admin. The visit was in response to a verbal death report for resident R1 filed by the facility.

During the visit, LPA interviewed 2 facility staff members and R1's roommate. LPA also obtained the following documents for resident R1: Physician's Report, Appraisal/Needs and Services Plan, and written death report. LPA also inspected R1's room. LPA requested Progress Notes for R1.

No deficiencies were cited at this time as per California Code of Regulations, Title 22.

This report was reviewed with Administrator Megan Miller and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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