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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202842
Report Date: 09/25/2025
Date Signed: 09/25/2025 12:37:41 PM

Document Has Been Signed on 09/25/2025 12:37 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:
09/25/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Stephanie Silva SantosTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Stephanie Silva Santos.

The purpose of the visit was to follow up on incident reports submitted by the facility, including:

- On 04/17/2025, the facility reported that on 04/16/2025 a facility van was involved in an accident while residents were in the vehicle. (Note: an internal investigation conducted by the facility identified the driver of the van as staff S1.)

- On 06/03/2025, the facility reported that on 06/02/2025, a staff reported that on 04/02/2025, two staff consumed marijuana in front of a resident and were under the influence of marijuana at the facility. (Note: an internal investigation conducted by the facility identified the two staff as S1 and S4.)

- On 07/08/2025, the facility reported that there were three incidents involving staff physically or emotionally abusing residents, including a staff grabbing a resident by the shirt and hair sometime in 03/17/2025, a staff throwing cheese at a resident and laughing at the resident on 03/28/2025, and a staff encouraging a resident to eat raw onions that occurred at an unspecified date. (Note: an internal investigation conducted by the facility identified the staff who allegedly grabbed the resident by the shirt and hair as S5, the staff who allegedly threw cheese at the resident as S6, and the staff who allegedly encouraged the resident to eat raw onions as S7)

See LIC9099-C pages for more information. Page 1 of 3.
NAME OF LICENSING PROGRAM MANAGER: Maria Partoza
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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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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: 09/25/2025
NARRATIVE
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- On 08/14/2025, the facility reported that on 08/14/2025, a knife had gone missing from the facility lock box.

During visit, LPA Marrufo obtained a written statement from staff S2 stating that staff S1 appeared to have blood shot red eyes, stumbling, and slurring his/her words and drove the van at 80 miles per hour in a 55 mile per hour zone while resident R1 was in the vehicle on 04/16/2025. LPA Marrufo obtained an internal investigation conducted by the facility which stated staff S3 stated S1 drove over the legal speed limit during the incident. The report states the van was dented as a result of S1 crashing the van into a fence. No injuries were observed after the incident.

During visit, LPA Marrufo obtained internal reports conducted by the facility investigating the alleged incidents that were reported on 06/03/2025 and 07/08/2025. Both reports arrived at an unsubstantiated finding.

During visit, LPA Marrufo observed the lock box and the locked cabinet where the lock box is stored. LPA Marrufo obtained a copy of the Sharp Count sheet that is used to record the counting of the sharp objects that are supposed to be stored inside the lock box. LPA also obtained a copy of the staff schedule, which indicates there are staff scheduled at all times at the facility. LPA obtained a copy of the Sharp Instrument Storage, Inventory, Use, and Disposal policy. During visit, LPA interviewed S4, who stated there have been no incidents of injuries due to stabbing or cutting at the facility. S4 stated the parents of the residents were notified that the knife had gone missing, a room search was conducted to search for the knife, and the sharp object storage policy is reviewed with staff during every staff meeting.



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

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
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: YAI RIVERSIDE EBSH
FACILITY NUMBER: 445202842
VISIT DATE: 09/25/2025
NARRATIVE
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LPA Marrufo informed ADM 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.

An Advisory Note was issued. See LIC9102 for more information.

Deficiencies were issued as per California Code of Regulations Title 22. See LIC809-D pages for more information.

This report was reviewed with ADM Stephanie Silva Santos and a copy of this report and appeal rights were provided.


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

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2025 12:37 PM - It Cannot Be Edited


Created By: David Marrufo On 09/25/2025 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: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2025
Section Cited
CCR
80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced
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Licensee agrees to submit a plan of correction by Plan of Correction Due Date of 09/26/2025 stating how the licensee will conduct in-service training with staff on how to be competent to provide the services necessary to meet
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by: On 04/16/2025, staff S1, while driving the facility van with resident R1 onboard, crashed the facility van into a fence, causing a dent in the vehicle, and afterwards drove the van over the speed limit at 80 miles per hour in a 55 miles per hour zone; additionally, staff S2 provided a written statement reporting that S1 appeared to have blood shot red eyes, stumbling, and slurring his/her words, which poses an immediate safety risk to residents in care.
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individual client needs, including following safe driving practices and not being under the influence of any drugs or illegal substances while on duty at the facility. Once training is completed, the licensee agrees to submit copies of staff training records, including names of staff trained, training dates, 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: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2025 12:37 PM - It Cannot Be Edited


Created By: David Marrufo On 09/25/2025 at 12:14 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: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2025
Section Cited
CCR
80061(b)(1)(E)

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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day
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Licensee agrees to conduct in-service training with staff on reporting any unusual incident or client absence which threatens the physical or emotional health or safety of any client within the next working day during its normal business hours and
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during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by: Licensee did not ensure that a written report of four unusual incidents which threatened the physical or emotional health or safety of a client were reported within seven days of the incident; the first incident involved two staff smoking marijuana in front of a resident occurred on 04/02/2025 and was not reported until 06/02/2025; the second, third, and fourth incidents were reported on 07/08/2025 and included a staff grabbing a resident by the shirt and hair on 03/17/2025, a staff throwing cheese at a resident and laughing at the resident on 03/28/2025, and a staff encouraging a resident to eat raw onions that occurred at an unspecified date; which pose a potential health and safety risk to residents in care.
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provide a written report to the licensing agency within seven days following the occurrence of the incident. Once training is completed, the licensee agrees to submit copies of staff training records, including names of staff trained, training dates, 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: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
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