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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201411
Report Date: 09/01/2023
Date Signed: 09/01/2023 12:21:50 PM

Document Has Been Signed on 09/01/2023 12:21 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: 19DATE:
09/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mauna MorrisTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Administrator Mauna Morris.

During visit, LPA Marrufo observed there to be 19 clients and 5 staff. LPA Marrufo interviewed staff S1-S5 as well as Administrator Morris. LPA Marrufo obtained copies of the following facility records during visit: Resident Roster from 08/25/2023, Staff Daily Sign-In/Out Sheet from August 2023, and August 2023 Calendar.

Upon review of records, LPA observed that the Resident Roster from 08/25/2023 indicates that there were 21 clients at the facility from 12:00 PM to 2:30 PM. The Staff Daily Sign-in/Out Sheet from August 2023 indicates that there were 5 staff at the facility from morning until 3:45 PM and Administrator Morris arrived at the facility at 2:00 PM.

A deficiency has been cited as per California Code of Regulations Title 22. See LIC809-D for more information.

The facility was cited for the same deficiency on 08/04/2023. Due to repeated violations, an immediate civil penalty of $250 has been assessed.

This report was reviewed with Administrator Morris and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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 09/01/2023 12:21 PM - It Cannot Be Edited


Created By: David Marrufo On 09/01/2023 at 12:00 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: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2023
Section Cited
CCR
82065.5(a)(1)

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Staff-Client Ratio (a)Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met:(1)For Regional Center clients, staffing shall be maintained as specified by the Regional Center.
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Administrator will submit a written plan of how the facility will maintain staff to client ratio of 1:4, including during breaks (restroom, snack, or diaper change) by POC date. Administrator understood and agreed.
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This requirement is not met as evidenced by: LPAs observed that Staff-Client Ratio (1:4) was not being met on 08/25/2023 when there were 5 staff and 21 cilents at the facility between 12:00 PM to 2:00 PM.
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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: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023


LIC809 (FAS) - (06/04)
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