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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202814
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:52:43 PM

Document Has Been Signed on 09/12/2024 03:52 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:KINSLEY MANORFACILITY NUMBER:
445202814
ADMINISTRATOR/
DIRECTOR:		BLESSING, KATHERINEFACILITY TYPE:
735
ADDRESS:2221 KINSLEY STREETTELEPHONE:
(831) 475-0888
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 4CENSUS: 4DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Michael CarloneTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analysts (LPAs) Santino Fortes, Manuel Monter, and LPA Marcella Tarin conducted an unannounced annual inspection visit, and met with Licensee (LC) Michael Carlone. LPA observed 2 staff and 2 clients.

LPAs toured the facility inside and out which included: kitchen, office area/living room, 3 resident rooms and 2 restrooms. LPAs observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The staff area of the facility which was an area in the living room was also inspected. The front yard and backyard of the facility was also inspected, along with the locked storage sheds. There was no obstruction to block the outdoor exits.

LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 73 degree F, and hot water temperature was measured at 108 degrees F in both facility restrooms.

The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested. Fire extinguishers were last serviced on December 22, 2023. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed and fire drills have been conducted monthly. The facility's last drill was on 7/19/24.

LPA interviewed 2 staff members and 2 residents. 2 residents were at day programs during the inspection.
LPA reviewed facility records for 3 staffs and records and P and I's for 4 clients, which were all found to be complete during review. LPA reviewed 4 clients medications and centrally stored medication records and found the centrally stored medication records to be complete.
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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Santino Fortes
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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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: KINSLEY MANOR
FACILITY NUMBER: 445202814
VISIT DATE: 09/12/2024
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No deficiencies were cited during today's visit as per California Code of Regulations Title 22. This report was reviewed with LC Michael Carlone and a copy of the signed report was provided.

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END OF REPORT

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Santino Fortes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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