445202723-9-10-2024-26-AS-MTAN-D8YRB7-20240910125217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202723
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:52:33 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/10/2024 12:52 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:	SEABRIGHT VILLA		FACILITY NUMBER:	445202723
ADMINISTRATOR/ DIRECTOR:	GHARAKHANIAN, CANDICE		FACILITY TYPE:	735
ADDRESS:	707 DARWIN ST		TELEPHONE:	(408) 461-0330
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY: 8		CENSUS: 7	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:55 AM
MET WITH:	Administrator, Candice Gharakhanian		TIME VISIT/ INSPECTION COMPLETED:	12:55 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 Analysts (LPAs) Marcella Tarin and Christine Dolores conducted an unannounced 1 year annual inspection on 09/10/2024 at 10:55am. LPAs met with Administrator Candice Gharakhanian. The facility serves developmentally disabled adults, age range 18 through 59. LPAs toured the facility inside and out with the Administrator to include the living room, dining room, kitchen, resident bedrooms, bathrooms, and backyard. All emergency exits were observed to be clear of obstruction. LPAs toured the kitchen and dining room. Facility has 7 days worth of nonperishable foods and 2 days worth of perishable food supply. Refrigerator temperature maintained at 30 degrees F and freezer temperature maintained at -0 degrees F. LPAs toured 2 out of 2 hallway bathrooms. Hand soap, hand dryers and functioning lights in 2 out of 2 bathrooms observed. Water temperature in 2 out of 2 hallway bathrooms measured at 108 degrees F. LPAs observed tags on fire extinguishers with an inspection date of 12/5/2023. LPAs tested and observed the carbon monoxide detectors to be operational. LPAs toured 3 residents bedrooms. 3 out of 3 resident bedrooms had functioning lights and storage space for resident belongings. LPAs reviewed 3 residents Centrally Stored Medication and Destruction Records (CSMDR). LPAs observed 3 out of 3 CSMDRs are complete with all medications accounted for. LPAs reviewed 3 out of 3 resident records. LPAs observed 3 out of 3 resident records as complete to include a medical assessment, TB result, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms. 3 out of 3 resident's P&I money were reviewed. LPAs observed R1 and R2 were missing P&I money and R3's had an excess of P&I. Administrator states R1 and R2 are in a community outing and staff pulled P&I money for residents. Administrator states R3's P&I balance is incorrect as extra money given by family was not logged in. See LIC809C.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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: SEABRIGHT VILLA	FACILITY NUMBER: 445202723
	VISIT DATE: 09/10/2024

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

LPAs reviewed 3 out of 3 staff records. LPAs observed 3 out of 3 staff records as complete. 3 out of 3 staff obtained fingerprint clearance, annual training, health screening, TB result, personnel record, and employee rights.

Emergency drills logs were reviewed. Facility conducts emergency drills monthly, with the last fire and earthquakes drills completed in August 2024. LPAs observed flashlights and first aid kits.

Facility has a portable backup generator located off-site incase of an emergency. Facility has an updated emergency disaster plan.

Documents were requested to update the facility file by 9/13/2024: LIC 500, LIC 308, Surety Bond, Administrator Certification, Lease Agreement, and updated 610D.

No deficiencies were cited per California Code of Regulations Title 22. This report was reviewed with Administrator Candice Gharakhanian and a copy of this report was provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2