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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202097
Report Date: 06/21/2024
Date Signed: 06/21/2024 11:43:06 AM

Document Has Been Signed on 06/21/2024 11:43 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:BAYSIDE ADULT DAY ACTIVITY PROGRAMFACILITY NUMBER:
445202097
ADMINISTRATOR/
DIRECTOR:
DAN DORANFACILITY TYPE:
775
ADDRESS:2301 17TH AVE.TELEPHONE:
(831) 475-0888
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 60CENSUS: 38DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Katherine BlessingTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Katherine Blessing, Director of Consumer Services.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the facility kitchen area and observed there to be locked drawers for cleaning supplies. The first aid kit was observed and found to be complete.

LPA toured the outside area. 1 out of 3 outside exit gates was damaged and unable to open. The exits on the other 2 out of 3 outdoor exits were found to operate properly and were clear of obstructions.

LPA toured two out of two hallway bathrooms and each bathroom had available soap and paper towels. The water temperatures in the bathroom sinks were 108 F and 110 F.

LPA Marrufo reviewed Centrally Stored Medication and Destruction Records (CSMDR) for the 2 out of 2 clients who have medications centrally stored at the facility. Both client CSMDRs were complete.

5 resident records were reviewed and found to be complete. 5 staff records were reviewed and staff S1 did not have a current first aid certification.

The Fire Inspection Record indicates that the smoke detectors were last tested on 04/02/2024. The Emergency Disaster Drill Log indicates the last drill was recorded on 05/2024.

Advisory Notes were issued. See LIC9012 pages for more information. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Katherine Blessing and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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