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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202740
Report Date: 10/22/2021
Date Signed: 10/22/2021 11:01:01 AM

Document Has Been Signed on 10/22/2021 11:01 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
CCLD Regional Office,
, CA
FACILITY NAME:COBBLESTONE MANORFACILITY NUMBER:
445202740
ADMINISTRATOR:JIMENEZ, ISABELFACILITY TYPE:
735
ADDRESS:75 LINDEN ROADTELEPHONE:
(831) 818-7981
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 4CENSUS: 3DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Isabel JimenezTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Isabel Jimenez Administrator.

LPA toured the facility inside and out to include the entry, bedrooms, bathrooms, kitchen, dining room, living room and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in locked cabinet in the office. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products. Hand sanitizer stations mounted throughout the facility for residents, staff and visitors. LPA observed sufficient supply of Personal Protective Equipment (PPE).

Staff disinfect high touch surfaces a minimum twice daily and as needed. Facility has a mitigation plan in place for prevent the spread of COVID-19 and other infectious diseases.

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, PPE usage and Fit Testing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Isabel Jimenez Administrator and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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