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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201621
Report Date: 08/19/2022
Date Signed: 08/19/2022 04:12:41 PM


Document Has Been Signed on 08/19/2022 04:12 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:DE UN AMORFACILITY NUMBER:
445201621
ADMINISTRATOR:FLETES, MARICELAFACILITY TYPE:
740
ADDRESS:460 EUREKA CANYON ROADTELEPHONE:
(831) 728-0303
CITY:CORRALITOSSTATE: CAZIP CODE:
95076
CAPACITY:25CENSUS: 20DATE:
08/19/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lusanta KaiyomTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Lusanta Kaiyom. The purpose of the visit was to conduct a health and safety check on the facility after it was reported that the facility has been under new management and ownership.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed there to be a visitor screening area with temperature reader at the entrance. There was a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. There was a PPE supply of at least 30-days. LPA Marrufo observed 10 residents watching a movie in the activity room.

LPA Marrufo requests that Lusanta Kaiyom submit a plan to CCL to come under a lease back agreement with the licensee of the current facility license by 08/23/2022. LPA Marrufo requests a copy of the resident roster along with the contact information of each resident’s responsible party be submitted to CCL by 08/22/2022.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Lusanta Kaiyom and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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