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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202381
Report Date: 02/27/2024
Date Signed: 02/27/2024 12:53:49 PM

Document Has Been Signed on 02/27/2024 12:53 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:SVS WATSONVILLE ADULT DAY PROGRAMFACILITY NUMBER:
445202381
ADMINISTRATOR:ALISON NOBLEFACILITY TYPE:
775
ADDRESS:1875 MAIN STREETTELEPHONE:
(831) 707-2280
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 60CENSUS: 57DATE:
02/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Danielle VerarTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Danielle Verar.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed the first aid kit and found it to be complete. LPA Marrufo toured the facility and found the outside exits to be clear of obstructions. LPA Marrufo toured 4 out of 4 resident bathrooms and found 2 out of the 4 had water temperatures at 85 F. During visit, staff were not able to test the smoke detector system or provide a report of the last time the smoke detector system was tested.

The emergency disaster drill log recorded the last drill was conducted on 12/20/2023.

LPA Marrufo reviewed resident and staff records and found them to be complete.

An Advisory Note was issued. See LIC9102 for more information.

A deficiency was cited as per California Code of Regulations, Title 22.

This report was reviewed with Danielle Verar and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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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Document Has Been Signed on 02/27/2024 12:53 PM - It Cannot Be Edited


Created By: David Marrufo On 02/27/2024 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SVS WATSONVILLE ADULT DAY PROGRAM
FACILITY NUMBER: 445202381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 4 bathroom sinks, which had water temperatures at 85 F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Licensee agrees to submit a Plan of Correction by POC date to ensure that water temperatures in the sinks of all resident bathrooms are between 105 F to 120 F. Licensee shall submit video evidence to CCL once bathroom sink temperatures are corrected.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024


LIC809 (FAS) - (06/04)
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