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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202247
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:01:52 PM


Document Has Been Signed on 08/03/2022 04:01 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: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: DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Jennifer FloresTIME COMPLETED:
04:03 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/03/2022 at 03:02pm. LPA met with facility Administrator Jennifer Flores (Admin).

LPA toured the facility, including entryway, living room, kitchen, dining room, laundry room, all bedrooms, all bathrooms, back patio, and back yard. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility infectious control has already been submitted. No prohibited items noted in resident rooms. 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. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in May 2022.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All restrooms stocked with paper towels. Water temperature observed to be 120*F. Facility temperature observed to be 77*F. Hand washing signs observed in all bathrooms, but they did not indicate 20 second requirement. LPA reminded administrator to post hand washing signs in all public bathrooms indicating the steps for how to properly wash hands. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. This report was reviewed with facility manager, Georgina Zavala. Administrator Jennifer Flores had a doctor's appointment, and gave Georgina permission to sign the report in her stead.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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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