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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202639
Report Date: 11/10/2022
Date Signed: 11/10/2022 05:05:58 PM

Document Has Been Signed on 11/10/2022 05:05 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:EDMUND MANORFACILITY NUMBER:
445202639
ADMINISTRATOR:CARLONE, MICHAELFACILITY TYPE:
735
ADDRESS:2077 EDMUND LANETELEPHONE:
(831) 475-0888
CITY:CAPITOLASTATE: CAZIP CODE:
95010
CAPACITY: 4CENSUS: 4DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Kate BlessingTIME COMPLETED:
11:22 AM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 11/10/2022 at 10:10am. LPA met with facility Administrator Kate Blessing (Admin).

Upon arrival at the facility, only cleaning staff were at the facility. Cleaning staff was deep cleaning the carpet while residents were at day program. LPA toured the facility, including living room, kitchen, dining room, laundry room, Office, 3 bedrooms, 4 bathrooms, and back yard. 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. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in December 2021. Smoke/carbon monoxide detectors tested and observed to be operational.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All shared restrooms stocked with paper towels. Water temperature observed to be 110.7 *F. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. This report was reviewed with Administrator Kate Blessing and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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