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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201411
Report Date: 06/13/2024
Date Signed: 06/13/2024 04:49:04 PM

Document Has Been Signed on 06/13/2024 04:49 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/
DIRECTOR:
MAUNA MORRISFACILITY TYPE:
775
ADDRESS:8056 VALENCIA ST.TELEPHONE:
(831) 662-8708
CITY:APTOSSTATE: CAZIP CODE:
95003
CAPACITY: 42CENSUS: 19DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Mauna MorrisTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Mauna Morris. During the visit, LPA observed 19 residents and 5 staff.

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.

ADM stated she does not have any residents who taking their medication during their visit at the day program. Chemicals and toxins are locked in the storage room. Three fire extinguishers(inspected May 2024), smoke alarms, carbon monoxide detector and emergency first aid kit were observed in the facility.

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 112 degrees F. Facility was observed to have a designated quite room for residents to isolate if needed.

LPA reviewed facility records for 3 residents. While reviewing residents records, LPA observed that Resident R1's needs and services plan is dated February 13, 2020 and his/her IPP is dated February 10, 2022. LPA observed that Resident R3's Needs and Services Plan, dated May 15, 2019 and his/her IPP is dated May 4, 2020. LPA also reviewed 3 staff records. LPA conducted interviews with 2 staff and 1 resident.
LPA informed ADM the facility phone number does not connect. ADM stated she would send board of resolutions letter with updated facility phone number.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Mauna Morris and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/13/2024 04:49 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/13/2024 at 04:28 PM
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: APTOS SENIOR ACTIVITY CENTER

FACILITY NUMBER: 445201411

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental, psychological, and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R1's needs and services plan is dated February 13, 2020 and his/her IPP is dated February 10, 2022. LPA observed that Resident R3's Needs and Services Plan, dated May 15, 2019 and his/her IPP is dated May 4, 2020. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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ADM stated she would send a copy of R1 and R3's updated needs and services plan. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the POC's by June 20, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
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