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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201411
Report Date: 08/15/2024
Date Signed: 08/15/2024 10:06:33 AM

Document Has Been Signed on 08/15/2024 10:06 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:APTOS SENIOR ACTIVITY CENTERFACILITY NUMBER:
445201411
ADMINISTRATOR/
DIRECTOR:		MAUNA MORRISFACILITY TYPE:
775
ADDRESS:8056 VALENCIA ST.TELEPHONE:
(831) 662-8707
CITY:APTOSSTATE: CAZIP CODE:
95003
CAPACITY: 42CENSUS: DATE:
08/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Program Coordinator Carole JarvisTIME VISIT/
INSPECTION COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA's) Manuel Monter and Marcela Yanez arrived unannounced to conduct a case management - other visit. LPA met with Program Coordinator (PC) Carole Jarvis. LPA's explained the purpose of the visit

During visit, a complaint report for complaint control number: 26-AS-20240604132035 was amended. The amended report was reviewed and handed to the ED.

On July 10, 2024, the facility was issued a civil penalty for a repeat violation. On July 10, 2024, the wrong civil penalty assessment form was generated.

During today visit, the correct civil penalty form (LIC 421FC) was reviewed and signed by the PC. LPA obtained the hard copy of the LIC 421FC. PC obtained a copy of the signed LIC 421FC.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Program Coordinator Carole Jarvis and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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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