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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202381
Report Date: 02/04/2025
Date Signed: 02/21/2025 10:43:37 AM

Document Has Been Signed on 02/21/2025 10:43 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:SVS WATSONVILLE ADULT DAY PROGRAMFACILITY NUMBER:
445202381
ADMINISTRATOR/
DIRECTOR:		ALISON NOBLEFACILITY TYPE:
775
ADDRESS:1875 MAIN STREETTELEPHONE:
(831) 707-2280
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 60CENSUS: 47DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Maria MendozaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Maria Mendoza, Program Director.

During visit, LPA toured the facility inside and out. LPA toured the activity rooms and gym areas. LPA reviewed the facility first aid kit and found it to be complete. LPA tested two out of two carbon monoxide detectors and found them to function properly when tested. LPA observed the smoke detector system and observed that the last recorded inspection of the smoke detector system occurred on 11/2024. LPA toured the facility exits and found them to be clear of obstructions.

LPA reviewed two out of two resident Centrally Stored Medication and Destruction Records and found them to be complete. LPA reviewed 7 resident records and found them to be complete. LPA reviewed 7 staff records and found 1 out of 7 reviewed staff records was missing a health screening form.

LPA toured four out of four resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 110 F, 110 F, 105 F, and 88 F.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information.

A civil penalty of $250 is being assessed today for a repeated violation. See LIC421FC for more information.

This report was reviewed with Program Director Maria Mendoza and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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 02/21/2025 10:43 AM - It Cannot Be Edited


Created By: David Marrufo On 02/04/2025 at 12:26 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: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of 7 staff records, Licensee did not ensure that 1 out of 7 reviewed staff records included a heath screening form, which poses a potential health risk to residents in care.
POC Due Date: 02/11/2025
Plan of Correction
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Licensee agrees to ensure that the staff whose health screening form was missing during inspection has a health screening form on file. Licensee agrees to submit a copy of the staff’s health screening form to department by Plan of Correction Date.
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: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/21/2025 10:43 AM - It Cannot Be Edited


Created By: David Marrufo On 02/04/2025 at 12:40 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: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
(e) Faucets used by clients for personal care shall deliver hot water. (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 of 4 out of 4 facility resident bathrooms, the licensee did not comply with the section cited above in 1 out of 4 bathrooms, which poses an immediate safety risk to persons in care. 1 out of 4 bathrooms had a bathroom sink with water temperature at 88 F.
POC Due Date: 02/05/2025
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: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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