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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202230
Report Date: 10/22/2021
Date Signed: 10/22/2021 12:24:24 PM

Document Has Been Signed on 10/22/2021 12:24 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
CCLD Regional Office,
, CA
FACILITY NAME:CASA PACIFICFACILITY NUMBER:
445202230
ADMINISTRATOR:ERIN MCLAUGHLINFACILITY TYPE:
772
ADDRESS:321 E. BEACH STREETTELEPHONE:
(831) 459-0444
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 12CENSUS: 9DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Serina CheeTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Serina Chee Clinician 2/Supervisor.

LPA toured the facility inside and out to include the entry, bedrooms, bathrooms, kitchen, dining room, living room and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in locked med cart in the office. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products. Hand sanitizer available to residents. LPA observed sufficient supply of Personal Protective Equipment (PPE). All staff have been Fit Test certified.

Staff disinfect high touch surfaces each shift and as needed. Signs posted included Visitor Policy, social distancing, hand washing, cough and cover, how to wear masks, stop the spread and what to do if you have COVID-19 symptoms.

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, PPE usage and Fit Testing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Serina Chee Clinician 2/Supervisor and a copy provided.








SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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