445202842-1-15-2026-26-AS-DMAO-DQD2TZ-20260115164134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202842
Report Date: 01/15/2026
Date Signed: 01/15/2026 04:41:43 PM

Document Has Been Signed on 01/15/2026 04:41 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 EBSH		FACILITY NUMBER:	445202842
ADMINISTRATOR/ DIRECTOR:	SILVA SANTOS, STEPHANIE		FACILITY TYPE:	737
ADDRESS:	479 RIVERSIDE RD		TELEPHONE:	(831) 240-4566
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY: 3		CENSUS:	DATE:	01/15/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Stephanie Silva Santos		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 on incidents reported to the department by the facility as well as a report of a semi-annual review conducted by the Department of Developmental Services (DDS) that was submitted to the department. On 11/27/2025, the facility submitted an Unusual Injury/Incident Report (IR) about an incident that occurred on 11/26/2025 at approximately 5:00 PM. The incident involved three staff who transported resident R1 to a nearby Walmart via van. When the van arrived at Walmart, R1 began hitting his/her head. Staff decided to send one staff, S1, into the Walmart to buy items for R1. The other two staff, S2 and S3, remained with R1 in the van. S2, the driver of the van, drove the van to a nearby park to help R1 self-sooth. After arriving at the park, R1 ran away from S2 and S3. S3 attempted to pursue R1 but lost visual contact with R1. The staff called 911 and 911 dispatch informed the staff that R1 was at the Walmart. The staff picked up R1 in the van and returned R1 to the facility by approximately 6:50 PM. During visit on 1/15/2026, LPA Marrufo interviewed staff S1 and S2. S1 stated R1 had gone missing for about an hour. S2 stated R1 had gone missing for about 10 minutes. Both S1 and S2 stated that staff had lost visual contact with R1 after R1 ran away at the park. See LIC809-C page for more information. Page 1 of 2.

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

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: 01/15/2026

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R1's Individualized Behavioral Support Plan includes supervision requirements for both Transportation and Recreational and Community situations. The Transportation requirements state, "From 6:30am to 10:00 pm, [R1] has a 3:1 staff ratio while riding in a vehicle (YAI van, taxi, Uber, etc.). DSP/RBT 3 will drive the YAI vehicle to transport [him/her]." The Recreational Community requirements state, "From 6:30am to 10:00pm DSP/RBT1 is within sight 0-3 feet, DSP/RBT 2 is in sight within 0-6 feet, and DSP/RBT 3 is at a distance (0-15 feet) to hear, see, and support during behaviors of concern and drive transportation. if [he/she] is escalated or unsafe his 3:1 staff will be within 0-3 feet to support, the DSP/RBT3 will be within 0-10 feet to support."

The facility submitted two IRs reporting missed resident medications. The first IR was sent on 10/25/2025 and reported that on 10/24/2025, staff observed that R1's medications that should have been taken on 10/23/2025 at 4:00 PM remained unopened, resulting in a missed dose. The second IR was sent on 10/30/2025 and reported that on 10/29/2025, staff observed that a medication for R2 had not been administered, resulting in a missed dose.

The DDS semi-annual review reported that due to a resident's behavior of throwing out and dumping food and consuming food prior to it being prepared for consumption, the facility staff had relocated resident food into the refrigerator located inside the garage, which is locked by a keypad and is inaccessible to residents.

During visit on 01/15/2026, LPA observed that there is a white board inside the locked cabinet. The white boards had a list of the food items stored in the garage refrigerator so that residents can request them. ADM stated that the residents have the key to their own snack cabinets.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. Two immediate civil penalties were assessed today for $250 each, totaling $500. See LIC421FC for more information. This report was reviewed with Administrator Stephanie Silva Santos and a copy of this report and appeal rights were provided.

Page 2 of 2. END REPORT.

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/15/2026 04:41 PM - It Cannot Be Edited

Created By: David Marrufo On 01/15/2026 at 04:09 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: 01/15/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/16/2026 Section Cited CCR 80065(a)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	Licensee agrees to submit a Plan of Correction by 01/16/2026 stating how the licensee will provide in-service training to staff to ensure that they meet all residents’ needs, including the residents’ supervision requirements during transportation and in
	8 9 10 11 12 13 14	by: Licensee did not ensure that staff followed R1’s individual client needs (R1’s Individualized Behavior Support Plan requires a 3:1 ratio while being transported and for staff to stay within sight of R1), which poses an immediate safety risk to residents in care. A civil penalty of $250 was assessed today for a repeated deficiency	8 9 10 11 12 13 14	community environments. Licensee agrees to submit staff training records to the department once training is concluded, including names of staff trained, training dates, training topics, and names and qualifications of trainers.
Type A 01/16/2026 Section Cited CCR80075(b)	1 2 3 4 5 6 7	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 by: Licensee did not ensure that staff did	1 2 3 4 5 6 7	Licensee agrees to submit a Plan of Correction by 01/16/2026 stating how the licensee will provide in-service training to staff to ensure that staff will assist residents with the self-administration of medications.
	8 9 10 11 12 13 14	not miss assisting the administration of two medication dosages for residents R1 and R2, which poses an immediate health risk to residents in care. A civil penalty of $250 was assessed today for a repeated deficiency	8 9 10 11 12 13 14	Licensee agrees to submit staff training records to the department once training is concluded, including names of staff trained, training dates, training topics, and names and qualifications of trainers.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:

	David Marrufo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC809 (FAS) - (06/04)

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