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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200583
Report Date: 06/29/2022
Date Signed: 06/29/2022 12:06:30 PM


Document Has Been Signed on 06/29/2022 12:06 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-2FACILITY NUMBER:
445200583
ADMINISTRATOR:MEGAN C. MILLERFACILITY TYPE:
740
ADDRESS:174 WILLOWBROOK DRIVETELEPHONE:
(831) 336-5196
CITY:BEN LOMONDSTATE: CAZIP CODE:
95005
CAPACITY:6CENSUS: 6DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Megan MillerTIME COMPLETED:
12:10 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 06/29/2022 at 10:40am. LPA met with facility Administrator Megan Miller (Admin). LPA toured the facility including medicine room, kitchen, living room, 4 resident rooms, 2 bathrooms, and designated smoking area

All staff members observed to be wearing masks. Admin confirmed that all residents and staff have been vaccinated. Facility Mitigation plan has already been submitted and approved. 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.

Facility water temperature observed to be 109.8*F. Fire extinguisher noted to have received inspection in May 2022. Smoke detectors observed to be fully operational. Facility observed to have 2 days supply of perishable food and 1 weeks supply of non-perishable food.

Facility noted to possess a 30-day supply of PPE. Facility observed to have designated entry point. Staff took LPA's temperature, and screened for symptoms. All restrooms observed to be stoked with paper towels and lidded trash cans. Hand washing signs observed in all bathrooms. Social distancing signs observed as posted throughout facility in all public areas.

No deficiencies cited during visit. This report reviewed with Facility Administrator Megan Miller 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: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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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