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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202247
Report Date: 03/09/2022
Date Signed: 03/10/2022 08:00:16 AM


Document Has Been Signed on 03/10/2022 08:00 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
CCLD Regional Office,
, CA



FACILITY NAME:TWIN LAKES MANORFACILITY NUMBER:
445202247
ADMINISTRATOR:JENNIFER FLORESFACILITY TYPE:
740
ADDRESS:777 VOLZ LANETELEPHONE:
(831) 477-1100
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:12CENSUS: 7DATE:
03/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Jennifer FloresTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the Amended LIC9099 and LIC9099D report dated August 2, 2021. LPA met with Jennifer Flores and explained the purpose of the visit.

LPA reviewed the reports with Jennifer Flores and a copy of this report and amended report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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