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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202230
Report Date: 10/08/2024
Date Signed: 02/10/2025 09:15:17 AM

Document Has Been Signed on 02/10/2025 09:15 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:CASA PACIFICFACILITY NUMBER:
445202230
ADMINISTRATOR/
DIRECTOR:
ERIN MCLAUGHLINFACILITY TYPE:
772
ADDRESS:321 E. BEACH STREETTELEPHONE:
(831) 459-0444
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 12CENSUS: 12DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Karen GrijalvaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Karen Grijalva, Program Manager.

During visit, LPA Marrufo toured the kitchen area. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed there to be a secured drawer for sharp objects.

LPA toured the rear living unit that contained three bedrooms and a bathroom. LPA observed each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke detectors in each bedroom and the carbon monoxide detector and found them to function properly when tested. LPA toured the bathroom and observed there to be available soap and paper towels. The light in the bathroom was functioning and the water temperature in the sink measured to be 114 F.

LPA toured three out of three bedrooms in the main building. Each bedroom had functioning lights and available bedding and clothing storage areas. The smoke detector in each bedroom and the carbon monoxide detector in the main building functioned properly when tested. LPA toured the bathroom in the main building and observed there to be working lights and available soap and paper towels. The water temperature in the bathroom sink measured at 114 F.

LPA toured the outside area and observed the outdoor exit to be clear of obstructions. LPA Marrufo reviewed Centrally Stored Medication and Destruction Records and Resident Records for five residents and found them to be complete. LPA reviewed five staff records and found them to be complete.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Karen Grijalva and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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