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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202401
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:56:11 AM


Document Has Been Signed on 08/03/2022 11:56 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: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: 27DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Josephine ArcillaTIME COMPLETED:
11:57 AM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/03/2022 at 10:02am. LPA met with facility Administrator Josephine Arcilla (Admin).

LPA began touring the facility inside and out including 2 living rooms, 2 kitchens, 2 dining rooms, 2 offices, 14 bathrooms, 25 bedrooms, 2 storage rooms, and 2 med rooms. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility Infectious Control plan 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. All restrooms were stocked with paper towels. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. LPA observed that no bathrooms had lidded trash cans. LPA told Administrator to replace trash cans in public bathrooms with lidded, non-touch operable trash cans.

Facility observed to have designated entry point. Staff took LPA's temperature, screened for symptoms, and recorded information in visitor log. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. 30 day supply of PPE observed. Fire Extinguishers observed to have been serviced on August 16th, 2021. Carbon monoxide/smoke detectors were observed throughout the facility.

No deficiencies cited during today's visit. This report was reviewed with Administrator Josephine Arcilla and a copy of the signed report was provided.
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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