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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200582
Report Date: 01/17/2024
Date Signed: 01/17/2024 10:11:34 AM

Document Has Been Signed on 01/17/2024 10:11 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
CENTRAL COAST CR/RES, 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: 34DATE:
01/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Megan MillerTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Monter arrived to the facility unannounced to conduct a case management visit regarding resident R1's eviction. LPA met with Administrator Megan Miller. LPA explained the purpose of the visit.

On December 15, 2023, the department received an eviction notice letter notification from the facility. The eviction letter stated, "Based upon a reassessment of the Resident's needs including mental health and medical conditions, conducted pursuant to applicable regulations, the Licensee or Administrator of the facility and the person who performs the assessment determine that the facility is not appropriate for the Resident and the Resident has been given the opportunity to relocate."

According to Title 22 code of regulations, 85068.5 Eviction Procedures (a)(4) A needs and services plan modification has been performed, as specified in Section 85068.3, which determined that the client's needs cannot be met by the facility and the client has been given an opportunity to relocate as specified in Section 85068.3(b)(3).

On January 4, 2024, LPA spoke with ADM. ADM stated the facility did the reassessment, but did not have documentation. ADM stated it wasn't policy/ normal step. ADM did send Functional capability forms for R1.

On January 12, 2024, the department received an updated needs and services plan, for resident R1, dated January 12, 2024.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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 01/17/2024 10:11 AM - It Cannot Be Edited


Created By: Manuel Monter On 01/17/2024 at 09:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WRC-1
FACILITY NUMBER: 445200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2024
Section Cited
CCR
85068.5(a)(4)

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85068.5(a)(4) A needs and services plan modification has been performed,... which determined that the client's needs cannot be met by the facility and the client has been given an opportunity to relocate as specified in Section 85068.3(b)(3). This requirement was not met as evidenced by;
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ADM stated she will send R1's updated needs and services plan. ADM stated she will send letter of understanding regarding the regulation.
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Based on interview with ADM, the facility did not update resident R1's needs plan, which determined the residents needs cannot be met. This poses/posed a potential health, safety or personal rights risk to persons in care.
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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 Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: WRC-1
FACILITY NUMBER: 445200582
VISIT DATE: 01/17/2024
NARRATIVE
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On January 17, 2024, LPA interviewed ADM. ADM stated, the facility didn't update resident R1's needs and services plan when the eviction letter was sent out. ADM stated she will send LPA the updated needs and services plan showing the residents needs have changed, and requires a higher level of care. ADM stated she didn't know that she needed to update the needs and services plan.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Megan Miller and a copy of the signed report & appeal rights were provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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