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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200907
Report Date: 05/23/2022
Date Signed: 05/23/2022 11:57:33 AM

Document Has Been Signed on 05/23/2022 11:57 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,
, CA
FACILITY NAME:APTOS HILLS RANCHFACILITY NUMBER:
445200907
ADMINISTRATOR:SANCHEZ, DEBI & BILLFACILITY TYPE:
735
ADDRESS:133 BROWNS VALLEY ROADTELEPHONE:
(831) 768-1698
CITY:CORRALITOSSTATE: CAZIP CODE:
95076
CAPACITY: 6CENSUS: 6DATE:
05/23/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bill Sanchez and Debi SanchezTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime with Bill Sanchez and Debi Sanchez Administrators, Lori Kopplinger RN, Program Clinical Consultant, and Romeo Manzano Licensing Program Manager to provide technical assistance to prevent and mitigate the spread of COVID 19 in the facility. LPA conducted a virtual tour of the facility.

During today's TA-Visit, recommendations were discussed as follows:

1. Post updated Visitor Policy, Mask Requirements at the central entry point to the facility
2. Utilize updated COVID 19 Symptom Screening Checklist
3. Continue to use paper towels instead of cloth towels for hand washing

LPA will forward video of PPE Donning and Doffing and Posters and updated COVID 19 Symptom Screening Checklist.

Report reviewed with Bill Sanchez and Debi Sanchez Administrators and a copy emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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