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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202741
Report Date: 11/20/2024
Date Signed: 11/20/2024 03:38:56 PM

Document Has Been Signed on 11/20/2024 03:38 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:SANDPIPER VILLAFACILITY NUMBER:
445202741
ADMINISTRATOR/
DIRECTOR:		OLIVARRIA, ALICIAFACILITY TYPE:
735
ADDRESS:418 SUMNER AVENUETELEPHONE:
(831) 818-7981
CITY:APTOSSTATE: CAZIP CODE:
95003
CAPACITY: 4CENSUS: 4DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator Alicia OlivarriaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Alicia Olivarria. LPA toured the facility inside and out with the ADM to include dining room, kitchen, client bedrooms, bathrooms, and exterior.

LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 40 degrees F and freezer maintained at 0 degrees F. LPA measured hot water temperature with a range of 112.8 to 114.2 degrees F. LPA observed medications were locked and inaccessible to clients.

LPAs toured client bedrooms. 4 out of 4 client bedrooms had functioning lights, storage space for personal belongings, clean bedding, and a dresser/table.

During tour of the exterior, LPA observed loose wooden panels on the backyard fence. LPA also observed a palm tree that had grown into the fence (on the side of house near trash storage), pushing wooden panels out towards the neighbors backyard. LPA advised ADM to have the two areas of the fence repaired. ADM had maintenance assess the area during visit and the fence will be repaired by 12/11/2024.

LPA reviewed 2 staff records. 2 out of 2 staff records were observed as complete, to include fingerprint clearance, annual training, health screening, TB results, personnel record, and employee rights.

LPA reviewed 2 client records. 2 out of 2 client records were observed as complete, to include a physician's report, TB results, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms.

See LIC 809C
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: SANDPIPER VILLA
FACILITY NUMBER: 445202741
VISIT DATE: 11/20/2024
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LPA reviewed 2 Centrally Stored Medication Destruction Records (CSMDRs). 2 out of 2 client CSMDRs were reviewed as complete, with all medication documented properly.

LPA reviewed 2 clients P&I with ADM. 2 out of 2 clients P&I were observed to be accurate and all money documented.

Fire extinguishers were last serviced on 01/09/2024. Smoke detectors functioned properly when tested by ADM. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed and drills are being conducted monthly. The last emergency drill was conducted on 11/02/2024. Facility has emergency disaster plan.

No deficiencies were cited during today's visit. A Technical Violation was issued. An exit interview was conducted with ADM Alicia Oliverria and a copy of this report was provided.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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