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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202842
Report Date: 04/04/2025
Date Signed: 04/04/2025 01:00:13 PM

Document Has Been Signed on 04/04/2025 01:00 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/
DIRECTOR:		SILVA SANTOS, STEPHANIEFACILITY TYPE:
737
ADDRESS:479 RIVERSIDE RDTELEPHONE:
(831) 240-4566
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 3CENSUS: 3DATE:
04/04/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Stephanie Silva SantosTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Stephanie Santos, Program Administrator (PA). The purpose of the visit was to follow up with three incidents self-reported by the facility to the department.

The first incident was reported on 03/04/2025. The incident occurred on 03/04/2025 and involved resident R1 swallowing a battery from a blood pressure machine that was in R1's bedroom.

The second incident was reported on 03/19/2025 and occurred on 03/19/2025. The second incident involved R1 using a mirror that was in R1's backpack to attempt to cut himself/herself.

The third incident was reported on 04/02/2025 and occurred on 04/02/2025. The third incident involved R1 swallowing R1's bedroom key and kinetic sand.

During visit, LPA Marrufo interviewed PA. PA stated that staff had left the blood pressure machine in R1's bedroom in the morning on the day of the incident. PA stated that the blood pressure machine should have been returned to a cabinet in the facility garage, but staff did not return the blood pressure machine. PA stated that due to personal rights of R1, staff are not able to sweep, or tour, R1's bedroom while R1 is not present in R1's bedroom. PA stated that when R1 returned to R1's bedroom in the evening, R1 rushed to the blood pressure machine, removed a battery, and swallowed a battery.

See LIC809-C page for more information. Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Sarah Yip
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
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: YAI RIVERSIDE EBSH
FACILITY NUMBER: 445202842
VISIT DATE: 04/04/2025
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PA stated there is not a check in/check out process for the blood pressure machine. PA stated that staff sweep the interior of the home every hour, but there was not a log kept at that time.

LPA Marrufo obtained a copy of R1's Individualized Behavioral Plan, dated 02/10/2025. R1's IPP states, "Environmental modifications: scan the environment and remove access to potentially dangerous items and/or continue to supervise access to potentially dangerous and/or small items that could be easily swallowed."

Regarding the second incident, PA stated R1 received the mirror as a prize for winning a game of bingo during an outing in the community. The outing was not organized by the facility. PA stated R1 had the mirror in R1's bag and due to personal rights reasons, the staff are not able to sweep R1's bag. R1 took the mirror and made attempts to cut himself/herself with the mirror. R1 was able to inflict a small scrape upon himself/herself that did not require first aid, according to PA. PA stated that a denial of rights for mirrors has been approved for R1 for 30 days.

Regarding the third incident, PA stated that R1 swallowed R1's bedroom key and kinetic sand. PA stated that kinetic sand was offered to R1 as part of R1's "store," a reward system for good behavior. PA stated a denial of rights has been approved so that R1 will not have access to keys or kinetic sand for 30 days. PA stated that PA is meeting with R1's care team to discuss changing R1's bedroom lock to an electronic lock with a pass code so that a physical key is not necessary.

LPA Marrufo discussed with PA Silva Santos the importance of keeping the facility free of any potentially dangerous items that R1 may attempt to consume, including ensuring that staff endorse with one another the use and return of the blood pressure machine. LPA Marrufo informed PA Stephanie Silva Santos of the Department’s technical support program (TSP) and will provide Community Care Licensing Division (CCLD) website https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers as a resource on TSP.

A deficiency was cited as per California Code of Regulations Title 22. Due to repeated violations, a civil penalty of $250 is being issued today. This report was reviewed with PA Stephanie Silva Santos and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Sarah Yip
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/04/2025 01:00 PM - It Cannot Be Edited


Created By: David Marrufo On 04/04/2025 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: YAI RIVERSIDE EBSH
FACILITY NUMBER: 445202842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2025
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 did not have access
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Licensee agrees to submit a Plan of Correction to CCL by POC date stating how the licensee shall train staff on ensuring that all residents' care and supervision needs are met, including following environmental modification (removing access to potentially
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to a blood pressure machine containing batteries, which R1 was able to swallow, posing an immediate safety risk to residents in care. **A $250 civil penalty was issued today for a repeated violation**
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dangerous items) requirements as specified in residents' Individualized Behavioral Support Plans.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sarah Yip
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025


LIC809 (FAS) - (06/04)
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