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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202740
Report Date: 09/09/2024
Date Signed: 09/09/2024 11:51:16 AM

Document Has Been Signed on 09/09/2024 11:51 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:
09/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME 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 conducted a Case Management visit and met with Administrator (ADM) Isabel Jimenez. The purpose of the visit was to tour and observe the facility prior to residents being relocated back into the facility from the emergency relocation site.

During visit, LPA Marrufo observed that the floor in the resident room that had water damage during the last visit was entirely replaced. LPA toured the outside of the facility and observed that the area outside the home that had leaking water no longer had any leaking. LPA Marrufo did not observe any signs of leaking or water damage within the home.

LPA observed furniture in place in 3 out of 3 bedrooms.

LPA observed the facility refrigerator was missing. During visit, ADM stated that the refrigerator had become damaged and a new refrigerator will be installed by Friday 09/13/2024. LPA observed there to be two refrigerators and food storage areas in the garage. ADM stated food is being stored at the relocation site and will be brought over when the residents return to the home. ADM stated that ADM will purchase more food later today.

LPA observed electricians and a construction crew continuing to work on the facility, including replacing missing electrical outlet covers. ADM stated all the electrical outlets will be covered before residents return to the facility. ADM stated the residents are planned to return to the facility tomorrow.

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: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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