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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201621
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:49:49 PM


Document Has Been Signed on 01/24/2024 03:49 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:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Saaj KaiyomTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Saaj Kaiyom.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen and basement food storage areas and observed the facility had a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. LPA Marrufo observed the kitchen area had locked drawers for sharp objects and medications.

LPA Marrufo toured 17 out of 17 resident bedrooms and observed each bedroom had working lights and available bedding and furniture. LPA Marrufo tested the hallway and resident smoke detectors and two out of two carbon monoxide detectors and found them to function properly when tested. LPA Marrufo observed 11 out of 11 resident bathrooms and found them to have available soap and paper towels and available lights. The bathroom water temperatures measured from 105-115 F.

LPA Marrufo toured the outside exits and found them to be clear of obstructions.

LPA Marrufo reviewed resident and staff records. Resident R1's Appraisal/Needs and Services Plan was missing from R1's Resident Record. The Emergency Disaster Drill Log recorded the last drill occurred on 01/15/2024.

An Advisory Note was issued. See LIC9102 for more information. No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator 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: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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