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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202842
Report Date: 07/18/2025
Date Signed: 07/18/2025 11:14:40 AM

Document Has Been Signed on 07/18/2025 11:14 AM - 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:
07/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Stephanie Silva SantosTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident visit and met with Administrator (ADM) Stephanie Silva Santos.

The purpose of the visit was to follow up with two Unusual Incident/Injury Reports (IRs) submitted by the facility. The first IR was submitted to the department on 07/08/2025. The IR reported that on 07/08/2025, the facility Quality Compliance (QC) Department informed Administrator Stephanie Silva that it will need to conduct three investigations after a staff reported allegations that staff pull resident R1's hair, throw items at R1, and encourage R1 to eat raw onions.

The second IR was reported to the department on 07/13/2025 and reported that at 2:00 AM on 07/13/2025, staff did not assist R2 in the self-administration of medication M1, resulting in R2 missing the dosage window for M1.

During visit, ADM stated that due to company policy, ADM would not be able to provide the internal investigation until QC has completed the investigation. LPA Marrufo requested that the internal investigation be submitted to the department once it is completed. ADM stated that one of the staff involved has resigned from the facility and two other involved staff are still employed and on schedule at the facility. ADM stated that the two involved staff are scheduled with other staff in ratio with them.

During visit, LPA Marrufo obtained a copy of the Medication Administration Record (MAR) which indicated that R1 was not assisted with the self-administration of M1 at 2:00 AM on 07/13/2025.
See LIC809-C page for more information. Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Maria Partoza
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2025
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)
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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: YAI RIVERSIDE EBSH
FACILITY NUMBER: 445202842
VISIT DATE: 07/18/2025
NARRATIVE
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A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. A civil penalty of $250 is being assessed today for a repeated violation. This report was reviewed with Administrator Stephanie Silva Santos and a copy of this report was provided.

Page 2 of 2.


END REPORT
NAME OF LICENSING PROGRAM MANAGER: Maria Partoza
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/18/2025 11:14 AM - It Cannot Be Edited


Created By: David Marrufo On 07/18/2025 at 10:58 AM
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: 07/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2025
Section Cited
CCR
80075(b)

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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced
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Licensee agrees to submit a Plan of Correction by POC Due Date that ensures that the licensee will conduct in-service training with staff on assisting residents with self-administration of prescribed medications, including ensuring that medications are not missed.
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by: Licensee did not ensure that staff assisted resident R2 with the self-administration of prescription medication M1, which poses an immediate health risk to residents in care. **A civil penalty of $250 was assessed today for a repeated deficiency**
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Once training is completed, Licensee agrees to provide training records to the Department, including names and dates of staff trained, training topics, and names and qualifications of trainers.

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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.
Maria Partoza
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
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