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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201410
Report Date: 08/23/2021
Date Signed: 08/26/2021 12:44:29 PM

Document Has Been Signed on 08/26/2021 12:44 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,
, CA
FACILITY NAME:PAJARO VALLEY TRAINING CENTERFACILITY NUMBER:
445201410
ADMINISTRATOR:MAUNA MORRISFACILITY TYPE:
775
ADDRESS:14 CARR STREETTELEPHONE:
(831) 761-8628
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 49CENSUS: 12DATE:
08/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mauna MorrisTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime with Mauna Morris Program Director, Roxanne Fangon Program Clinical Consultant (PCC), and Jackie Jin Licensing Program Manager. The purpose of the visit was to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities.

LPA conducted a virtual tour of the facility. LPA, PCC and LPM reviewed the facility policies and procedures to include screening, disinfecting, supplies, staffing, training, PPE usage, isolation protocols and social distancing.

The following recommendations were discussed:

1. Post 20 Seconds Hand washing signs in bathrooms
2. Staff wear surgical masks during shifts
3. Staff wearing N95s conduct seal checks and be Fit Tested
4. Maintain PPE supply cart outside Isolation room when required.

Signage for Hand washing and Donning and Doffing of PPE forwarded.

LPA reviewed report with Mauna Morris Program Director and copy emailed for signature purposes.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE:
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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