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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202842
Report Date: 10/05/2023
Date Signed: 10/05/2023 12:28:14 PM

Document Has Been Signed on 10/05/2023 12:28 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:YAI RIVERSIDE EBSHFACILITY NUMBER:
445202842
ADMINISTRATOR:SILVA SANTOS, STEPHANIEFACILITY TYPE:
737
ADDRESS:479 RIVERSIDE RDTELEPHONE:
(646) 946-1389
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 3CENSUS: 0DATE:
10/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Stephanie Silva SantosTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Pre-Licensing visit and met with Administrator Stephanie Silva Santos.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed the storage areas in the kitchen that will be locked to place sharp objects and cleaning supplies. LPA observed a locked medication storage cart, emergency supplies and generator, and laundry room. LPA Marrufo observed 3 out of 3 bedrooms and observed them to have available bedding and functioning lights. LPA observed 2 out of 2 bathrooms and observed the water temperature to be 117 F. LPA Marrufo tested the fire alarm system and it functioned properly when tested. LPA observed Resident Rights posters were posted inside the facility.

The outdoor area exits were clear of obstructions. LPA observed a fence in the outside garden area was wobbly when leaned upon. LPA observed that the facility main telephone number and mobile telephone number are for telephone numbers based in the corporate headquarters and are not telephone numbers for the facility.

Advisory Notes were made. See LIC9102 for more information.

LPA Marrufo reviewed Component III with facility Administrator Stephanie Silva Santos.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Stephanie Silva Santos and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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