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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202178
Report Date: 09/01/2022
Date Signed: 09/01/2022 04:41:15 PM

Document Has Been Signed on 09/01/2022 04:41 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:OPAL CLIFF RESIDENTIAL CENTERFACILITY NUMBER:
445202178
ADMINISTRATOR:MULIFANUA ASUEGAFACILITY TYPE:
735
ADDRESS:4795 OPAL CLIFF DR.TELEPHONE:
(831) 420-0120
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 15CENSUS: 15DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:26 PM
MET WITH:James RussellTIME COMPLETED:
04:44 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 09/01/2022 at 03:26pm. LPA met with facility Special Projects Manager James Russell (SPM).

LPA began touring the facility inside and out including 8 bedrooms, 5 bathrooms, 4 staff offices, 2 living rooms, sitting room, and patio. All staff members observed to be wearing masks. SPM confirmed that all staff and 93% of residents have been vaccinated.

All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. All restrooms stocked with paper towels. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. LPA observed that all bathrooms had lidded trash cans. Water temperature observed to be 105.3 *F and 110.7*F in 2 facility bathrooms.

Facility observed to have designated entry point. Staff took LPA's temperature, screened for symptoms, and recorded information in visitor log. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. 30 day supply of PPE observed. Fire Extinguishers observed to have been serviced on November 2021. Carbon monoxide/smoke detectors were tested and observed to be working throughout the facility.

LPA observed locks on refrigerator and freezer.

Deficiency cited during visit. See LIC 809-D. This report reviewed with Special Projects Manager James Russell and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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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Document Has Been Signed on 09/01/2022 04:41 PM - It Cannot Be Edited


Created By: Ryker Heberle On 09/01/2022 at 04:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: OPAL CLIFF RESIDENTIAL CENTER
FACILITY NUMBER: 445202178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(3)
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to refrigeration units possessing locks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2022
Plan of Correction
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Licensee is to remove locks from food refirgeration and freezer units. Licensee shall provide photo documentation of removed locks to the department by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
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