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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202740
Report Date: 08/23/2024
Date Signed: 08/23/2024 11:59:59 AM

Document Has Been Signed on 08/23/2024 11:59 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:COBBLESTONE MANORFACILITY NUMBER:
445202740
ADMINISTRATOR/
DIRECTOR:
JIMENEZ, ISABELFACILITY TYPE:
735
ADDRESS:75 LINDEN ROADTELEPHONE:
(831) 818-7981
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 4CENSUS: 0DATE:
08/23/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Isabel JimenezTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) David Marrufo arrived at the facility and conducted a Case Management - Health Check and met with Administrator (ADM) Isabel Jimenez.

The purpose of the visit was to conduct a health check after the facility reported via telephone call to CCL office on 08/23/2024 that on 08/23/2024 there was a water leakage at the facility. On 08/23/2024 at 5:30 PM, 4 out of 4 residents were evacuated from the facility and relocated to an emergency relocation site.

During visit, LPA toured the facility inside and out. No residents were observed inside the facility during visit. LPA observed a water leakage at the exterior of the facility property outside of the facility fence on Mountain View Road.

LPA observed rotting wooden flooring in one of the facility bedrooms.

ADM stated during visit that the water leakage was caused by a pipe that burst underneath the facility floor. ADM stated the water has been pumped out from underneath the facility floor. ADM stated that the estimated time of repair will be two weeks. ADM stated the residents have been relocated to an emergency relocation site and all resident and staff records, medications, and essential personal belongings have been transported to the emergency relocation site. ADM stated medications are being stored in locked containers at the relocation site.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with ADM Isabel Jimenez and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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