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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201411
Report Date: 07/07/2022
Date Signed: 07/07/2022 04:30:02 PM

Document Has Been Signed on 07/07/2022 04:30 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:APTOS SENIOR ACTIVITY CENTERFACILITY NUMBER:
445201411
ADMINISTRATOR:MAUNA MORRISFACILITY TYPE:
775
ADDRESS:8056 VALENCIA ST.TELEPHONE:
(831) 662-8708
CITY:APTOSSTATE: CAZIP CODE:
95003
CAPACITY: 42CENSUS: DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:43 PM
MET WITH:Carole JarvisTIME COMPLETED:
04:33 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced Required - 1 Year visit on 05/31/2022 at 02:01pm and met with Program Director Carole Jarvis (Admin).

LPA toured the facility. The facility is currently operating in a reduced capacity due to the COVID-19 pandemic, offering online services to most of its clients. LPA toured the reception area, activity room, staff kitchen, 2 bathrooms, isolation room, storage room, and 2 offices. LPA was screened for symptoms and temperature upon entrance into the facility at designated entry point. All staff members observed to be wearing masks. LPA observed COVID-19 related posters displayed throughout the facility. LPA observed that the facility has a 30 day supply of PPE.

No prohibited items noted in facility. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. Food is not offered to clients at the facility, nor is medication currently being administered at the facility. Fire extinguishers observed to have been inspected in May of 2022.

All restrooms stocked with paper towels. Hand washing signs observed in all bathrooms. Facility water temperature measured at 115.9 *F. Facility was observed to have a designated room for residents to isolate in the event of manifestation of symptoms. Vaccination rate for staff and clients is currently at 100%.

No deficiencies cited during today's visit. This report was reviewed with Program Director Carole Jarvis and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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