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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202878
Report Date: 01/24/2025
Date Signed: 01/29/2025 09:57:47 AM

Document Has Been Signed on 01/29/2025 09:57 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:EASTLAKE VILLA HOME CAREFACILITY NUMBER:
445202878
ADMINISTRATOR/
DIRECTOR:		RECINTO, RACHELLEFACILITY TYPE:
740
ADDRESS:591 ARLENE DRIVETELEPHONE:
(213) 400-4341
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 10CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Yuly AritaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Yuly Arita, Office Manager.

During visit, LPA toured the facility inside and out. LPA toured the kitchen area. LPA observed there to be locked drawers for sharp objects and cleaning supplies. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA reviewed the first aid kit and found it to be complete.

LPA toured the hallways and 6 out of 6 resident rooms. The smoke detectors in the hallways and in the resident rooms all functioned properly when tested. Two out of two carbon monoxide detectors functioned properly when tested.

LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels as well as functioning lights. The showers had anti-slip mats and shower chairs. The water temperatures in both bathroom sinks measured at 117 F.

LPA toured the garage area and observed the garage door had a doorknob that could be locked and unlocked from inside the house. LPA observed that there were laundry detergents on top of the washing machine. LPA advised staff to either change the lock on the garage door so that it cannot be unlocked by residents or to install locks on one of the garage cabinets and store the laundry detergent in the locked cabinet. During visit, staff installed a lock on one of the cabinet inside the garage and placed the laundry detergent inside the locked cabinet.

LPA toured the outside of the facility and found both exits to be clear of obstructions. See LIC809-D page for more information. Page 1 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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 3
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: EASTLAKE VILLA HOME CARE
FACILITY NUMBER: 445202878
VISIT DATE: 01/24/2025
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LPA Marrufo reviewed the Centrally Stored Medication and Destruction Record (CSMDR) during visit for residents R1-R5. The following errors were found in the CSMDR: R3 had two medications that were not recorded and R4 had one medication that was not recorded.

LPA Marrufo reviewed the resident records for residents R1-R5 and found them to be complete.

LPA reviewed the staff records of five staff and found them to be complete.

An advisory note was issued. See LIC9102 for more information.

A deficiencies was cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Yuly Arita and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2025 09:57 AM - It Cannot Be Edited


Created By: David Marrufo On 01/24/2025 at 02:32 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: EASTLAKE VILLA HOME CARE
FACILITY NUMBER: 445202878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)(A)-(F)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of 5 out of 5 resident Centrally Stored Medication and Destruction Records (CSMDR), Licensee did not ensure that resident R3 did not have two medications missing from the Centrally Stored Medication and Destruction Records (CSMDR) and R4 did not have one medication missing from the CSMDR, which poses a potential health risk to residents in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee agrees to audit and update all resident Centrally Stored Medication and Destruction Records (CSMDR) and provide in-service training to staff to ensure staff know how to record all required information for all resident prescription medications in the CSMDR. Once training is completed, the Licensee shall submit copies of staff training records, including names of staff trained, training dates, training topics, and names and qualifications of trainers.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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