<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202401
Report Date: 08/29/2024
Date Signed: 08/29/2024 01:48:08 PM


Document Has Been Signed on 08/29/2024 01:48 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:VALLEY HAVEN IIIFACILITY NUMBER:
445202401
ADMINISTRATOR:JOSEPHINE ARCILLAFACILITY TYPE:
740
ADDRESS:2266 CHANTICLEER AVE.TELEPHONE:
(831) 818-8372
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:48CENSUS: 28DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Josephine ArcillaTIME COMPLETED:
01:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator/Licensee, Josephine Arcilla.

During visit, LPA toured the facility with the Licensee to include Blossom Home, Wisteria Place, garage, storage tent, and exterior. All fire exits routes are free and clear of obstruction. Facility staff present are fingerprint cleared and associated to the facility. Chemicals, sharp objects, and medications observed secured. Cameras observed in the common areas. Fire extinguishers last serviced on 09/20/2023.

LPA entered into 10 resident bedrooms in Blossom Home. Bedrooms equipped with adequate lighting and proper furniture. Bedroom #9's sliding door was difficult to open. During visit, Licensee fixed the sliding door. Bedroom #4's screen door needed repair. During visit, Licensee fixed the screen door. Bathroom hot water temperature maintained between 106 and 122 degrees F. Bathroom showers equipped with non-slid mats and grab bars. Carbon monoxide detector present. Activities calendar and menu posted in a visible area. Residents observed participating in activities during visit.

LPA entered into 7 bedrooms in Wisteria Place. Bedrooms equipped with adequate lighting and proper furniture. Bedroom #7 observed with 2 half rails making a full bed rail which was not in use. Licensee states the resident only has an order for half rails. During visit, staff removed 1 of the half rails from the bed. Licensee was advised. Bathroom hot water temperature in bedroom #9 maintained at 112 degrees F. Bathroom shower equipped with non-slid mats and grab bars. Carbon monoxide detector present. Activities calendar and menu posted in a visible area. Residents observed participating in activities during visit. SEE LIC809-C.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: VALLEY HAVEN III
FACILITY NUMBER: 445202401
VISIT DATE: 08/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility is equipped with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperatures maintained between 30 - 40 degrees F. Freezer temperatures maintained below 0 degrees F.

5 staff files were reviewed and observed maintained. 5 out of 5 staff are fingerprint cleared and CPR/1st Aid certified. 5 staff are provided annual training. 5 resident files were reviewed and observed maintained. LPA reviewed residents orders for oxygen, half bed rails, and a CPAP machine. 5 resident's centrally stored medications and records were reviewed with staff. No issues noted during review.

Posters observed in Blossom Home and Wisteria Home to include the licensing complaint poster, ombudsman poster, and facility license.

Facility has an infection control plan. Hand sanitizer and gloves observed throughout the facility. Facility has an updated emergency disaster plan. Emergency drills are being conducted quarterly. LPA observed 2 small generators which may be used for resident's who require oxygen upon a power outage. Licensee states they have 3 large generators in case of a power outage.

Documents obtained to update the facility file: Emergency Disaster plan. Licensee will email the facility's updated LIC500. Licensee/Administrator names observed on the pending Administrator Certificate list.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator/Licensee Josephine Arcilla and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2