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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
445202356
Report Date:
10/11/2023
Date Signed:
10/11/2023 11:05:10 AM
Document Has Been Signed on
10/11/2023 11:05 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:
MONTECITO MANOR
FACILITY NUMBER:
445202356
ADMINISTRATOR:
JOLENE SICLEY
FACILITY TYPE:
740
ADDRESS:
311 MONTECITO AVE.
TELEPHONE:
(831) 724-3055
CITY:
WATSONVILLE
STATE:
CA
ZIP CODE:
95076
CAPACITY:
85
CENSUS:
51
DATE:
10/11/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:15 AM
MET WITH:
Lexi Rodriguez
TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Lexi Rodriguez.
The purpose of the visit was to amend a report from 08/10/2023 to change the allegation finding from "unsubstantiated" to "needs further investigation."
No deficiencies were cited at this time as per California Code of Regulations Title 22.
This report was reviewed with Lexi Rodriguez and a copy of the report was provided.
SUPERVISOR'S NAME:
Sarah Yip
TELEPHONE:
(408) 324-2131
LICENSING EVALUATOR NAME:
David Marrufo
TELEPHONE:
(650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE:
10/11/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/11/2023
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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