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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202740
Report Date: 11/15/2024
Date Signed: 11/15/2024 03:45:04 PM

Document Has Been Signed on 11/15/2024 03:45 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/
DIRECTOR:
JIMENEZ, ISABELFACILITY TYPE:
735
ADDRESS:75 LINDEN ROADTELEPHONE:
(831) 818-7981
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 4CENSUS: 4DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Isabel JimenezTIME VISIT/
INSPECTION 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 (ADM) Isabel Jimenez.

During visit, LPA toured the inside and outside of the facility. LPA toured 3 out of 3 resident bedrooms and observed each bedroom to have working lights and available clothing storage and bedding. LPA tested the carbon monoxide detector in the hallway and it functioned properly when tested. LPA tested the smoke detectors in 3 out of 3 resident bedrooms and in the hallway and all smoke detectors functioned properly when tested.

LPA toured 1 out of 1 resident bathroom. The bathroom had working lights and available soap and paper towels. The water temperature in the bathroom sink measured at 119 F. LPA toured the kitchen area and observed locked storage areas for sharp objects and cleaning supplies. LPA toured the facility food supply in the kitchen area and garage area and found there to be a perishable food supply of at least 3 days and a non-perishable food supply of at least seven days.

LPA toured the outside area and found the exits to be clear of obstructions.

LPA reviewed the Personal and Incidental Money Log, the Centrally Stored Medication and Destruction Record, and the Resident Record for 4 out of 4 residents and found them to be complete. 4 staff records were reviewed and found to be complete.

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: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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