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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201411
Report Date: 08/04/2023
Date Signed: 08/04/2023 01:51:58 PM

Document Has Been Signed on 08/04/2023 01:51 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: 20DATE:
08/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:ADM Mauna MorrisTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA) Manuel Monter & Simi Rai conducted an unannounced Required - 1 Year visit on 08/4/2023 and met with Administrator (ADM) Mauna Morris.

LPA toured the facility inside and out. LPA's observed four staff during tour of the facility. ADM arrived to the facility sometime after the tour was completed. LPA toured the reception area, activity room, staff kitchen, 2 bathrooms, isolation room, storage room, and 2 offices. The facility does not provide meals as clients bring their own meals and snacks from their respective homes. All rooms in facility noted to be clean and well maintained. All emergency exits noted to be clear of obstruction.

Medication currently being administered at the facility for 2 residents. Medication is stored in ADM's office in a locked cabinet. Chemicals and toxins are locked in the storage room. Three fire extinguishers(inspected May 2023), smoke alarms, carbon monoxide detector and emergency first aid kit were observed in the facility. Fire inspection is conducted yearly and emergency drills are conducted monthly(last drill conducted on June 2023).

All restrooms stocked with paper towels, soap, and paper supplies were observed to be available. Facility water temperature measured ranged from 109 degrees F to 111 degrees F. Facility was observed to have a designated quite room for residents to isolate if needed.

LPA's interviewed 3 staff and 2 residents. 3 Staff records were reviewed with current first aid, health screening and clearances. 3 Client files were reviewed to be current and complete. The Day Program does not handle P&I money.

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: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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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