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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201621
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:33:22 PM


Document Has Been Signed on 11/17/2023 03:33 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:
11/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Saaj KaiyomTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Saaj Kaiyom. The purpose of the visit was to observe for sharp objects and unsecured prescription medications in the facility as well as inspecting staff records to ensure that Health Screening forms were present. The facility had previously been cited for unsecured sharps and prescription medications and a missing staff Health Screening form as part of a Pre-Licensing visit.

During visit, LPA Marrufo toured and observed 17 out of 17 resident rooms and did not observe any unsecured sharp objects or prescription medications. LPA Marrufo reviewed 5 staff records and did not observe any missing Health Screening forms.

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

This report was reviewed with 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: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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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