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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201621
Report Date: 03/17/2023
Date Signed: 03/17/2023 11:39:02 AM


Document Has Been Signed on 03/17/2023 11:39 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: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: 19DATE:
03/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Saaj KaiyomTIME COMPLETED:
11:45 AM
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***The following report was originally generated on 03/15/2023 under license number 445202888 and is now being generated under license number 445201621. LPA Marrufo requests the updated Plan of Operation regarding the impacts from the building damage to be submitted by 03/20/2023.***
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Saaj Kaiyom. The purpose of the visit was to conduct a safety check on the facility after it was reported that a tree had fallen on the facility building.

During visit, LPA Marrufo toured the facility. LPA Marrufo observed the outside patio area where a cluster of trees had fallen. LPA observed the outside patio and roof to have impact damage from the trees. A crew of workers was on site removing the tree. LPA Marrufo photographed the impact area as well as the remains of the tree. Mr. Kaiyom reported that there were no injuries from the fallen trees.

LPA Marrufo observed that the door to the wing of the facility that is located near the impact area had a sign posted from the County of Santa Cruz stating that the area beyond the door was under restricted use. The residents who resided on the impacted wing of the building were relocated to other parts of the facility. LPA Marrufo observed two male residents relocated to the living room. One female resident was observed to have been relocated to a vacant bedroom on the opposite side of the building. Another female resident had her bed relocated to the recreation room. Mr. Kaiyom confirmed that those four residents, two male and two female, were the only residents who had to be relocated to the other side of the building.

LPA Marrufo observed the resident medications and staff and resident records to be relocated in another room in the building away from the impacted area. LPA Marrufo advised Mr. Kaiyom to submit an Unusual Incident Report for the fallen trees. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Mr. Saaj 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: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023
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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