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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201410
Report Date: 07/18/2024
Date Signed: 07/18/2024 11:58:06 AM

Document Has Been Signed on 07/18/2024 11:58 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:PAJARO VALLEY TRAINING CENTERFACILITY NUMBER:
445201410
ADMINISTRATOR/
DIRECTOR:		MAUNA MORRISFACILITY TYPE:
775
ADDRESS:14 CARR STREETTELEPHONE:
(831) 761-8628
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 49CENSUS: 32DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mauna MorrisTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Administrator Mauna Morris.

During visit, LPA toured the facility inside and out. LPA checked 2 out of 2 carbon monoxide detectors and each detector functioned properly when tested. LPA Marrufo obtained a copy of the fire alarm inspection invoice dated 05/10/2024 from a fire alarm system maintenance contractor and an Inspection Report from local fire department dated 07/17/2024 which stated the facility was in compliance. LPA toured the facility kitchen area and found there to be a locked cabinet for cleaning supplies. LPA toured 3 out of 3 resident bathrooms and found the water temperatures to be between 113-114 F. LPA toured the outside area and found the exits to be clear of obstructions.

LPA reviewed resident records for 5 residents. Resident R1 was missing an Admission Agreement and an LIC613 Personal Rights Form. Resident R2 was missing an Admission Agreement and Consent Form for Medical Treatment. LPA reviewed 5 staff records. Staff S1 was missing an LIC503 Health Screening Form.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information. Advisory Notes were issued. See LIC9102 pages for more information. This report was reviewed with Administrator Mauna Morris and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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 07/18/2024 11:58 AM - It Cannot Be Edited


Created By: David Marrufo On 07/18/2024 at 11:31 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: PAJARO VALLEY TRAINING CENTER
FACILITY NUMBER: 445201410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2024
Section Cited

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80070 Client Records (b) Each record must contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 80068. This requirement was not met as evidenced
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by: Licensee did not ensure that residents R1 and R2 had Admission Agreements in their client records, which poses a potential personal rights risk to residents in care.
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Type B
07/25/2024
Section Cited

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80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the
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following information: (10) A health screening as specified in Section 80065(g). This requirement was not met as evidenced by: Licensee did not ensure that staff S1’s personnel record contained a Health Screening form, which poses a potential health risk to residents 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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
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