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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202740
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:49:52 PM

Document Has Been Signed on 11/27/2023 03:49 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:COBBLESTONE MANORFACILITY NUMBER:
445202740
ADMINISTRATOR:JIMENEZ, ISABELFACILITY TYPE:
735
ADDRESS:75 LINDEN ROADTELEPHONE:
(831) 818-7981
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 4CENSUS: 4DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Isabel JimenezTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Isabel Jimenez.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the facility kitchen and observed the sharp objects and chemical cleaning supplies were stored in locked cabinets. LPA Marrufo observed no expired food during visit. LPA Marrufo observed a 2 day perishable food supply and a 7 day non-perishable food supply.

LPA Marrufo observed the facility bathroom had working lights, grab bars, and available soap and paper towels. The bathroom sink water temperature measured at 118 F. LPA Marrufo toured 3 out of 3 resident bedrooms and observed each bedroom to have available bedding and dresser drawers and functioning lights. LPA tested 6 out of 6 smoke detectors and 1 out of 1 carbon monoxide detectors and found them all to be functional when tested. LPA Marrufo toured the outside area and found the exits were clear of obstructions.

LPA Marrufo reviewed 5 out of 5 staff files and 4 out of 4 resident files and found them to be complete. 4 out of 4 resident Personal and Incidental Monies Logs were reviewed and found to be complete. 4 out of 4 resident Centrally Stored Medication Logs were reviewed and 2 out of 4 residents had a medication that was missing from the Centrally Stored Medication Log. Administrator Jimenez entered the missing medications into the Centrally Stored Medication Log during visit. The Emergency Disaster Drill Log was reviewed and the last drills were conducted on 10/12/2023 and 11/08/2023.

An Advisory Note was issued. See LIC9102 for more information. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Isabel Jimenez and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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