445202878-1-6-2026-26-AS-DMAO-DQ42AL-20260106161342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202878
Report Date: 01/06/2026
Date Signed: 01/06/2026 04:13:53 PM

Document Has Been Signed on 01/06/2026 04:13 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:	EASTLAKE VILLA HOME CARE		FACILITY NUMBER:	445202878
ADMINISTRATOR/ DIRECTOR:	RECINTO, RACHELLE		FACILITY TYPE:	740
ADDRESS:	591 ARLENE DRIVE		TELEPHONE:	(213) 400-4341
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY: 10		CENSUS: 5	DATE:	01/06/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Tyrone Vega		TIME VISIT/ INSPECTION COMPLETED:	04:30 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 Required - 1 Year visit and met with Tyrone Vega. During visit, LPA toured the facility inside and out. During visit, LPA toured the kitchen area and observed there to be locked cabinets for sharp objects and medications. 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 toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 116 F. LPA toured six out of six bedrooms. Each bedroom had working lights and available bedding and clothing storage. LPA tested the smoke detectors in the hallways and resident bedrooms. Each smoke detector functioned properly when tested. LPA tested the carbon monoxide detector in the hallway and it functioned properly when tested. LPA toured the outside area and found the exits to be clear of obstructions. LPA reviewed the Centrally Stored Medication and Destruction Records (CSMDR) for residents R1-R5. Resident R1 had one medication missing from the CSMDR and R2 had two medications missing from the CSMDR. LPA reviewed the resident records of R1-R5 and found them to be complete. LPA reviewed five staff records and found them to be complete. 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: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

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: EASTLAKE VILLA HOME CARE	FACILITY NUMBER: 445202878
	VISIT DATE: 01/06/2026

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 was issued today for $250 for a repeated violation. See LIC421FC for more information.

LPA Marrufo requests that the following records be updated and copies sent to the department by 01/13/2026:

LIC500 Personnel Report
LIC308 Designation of Administrative Responsibility
Liability Insurance
LIC610 Emergency Disaster Plan

This report was reviewed with Tyrone Vega and a copy of this report was 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: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/06/2026 04:13 PM - It Cannot Be Edited

Created By: David Marrufo On 01/06/2026 at 04:00 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: 01/06/2026

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
1 2 3 4	Based on review of 5 out of 5 resident Centrally Stored Medication and Destruction Records (CSMDR), Licensee did not ensure that resident R1 did not have one medication missing from the Centrally Stored Medication and Destruction Records (CSMDR) and R2 did not have two medications missing from the CSMDR, which poses a potential health risk to residents in care. A civil penalty of $250 was assessed today for a repeated violation
	POC Due Date: 01/13/2026
	Plan of Correction
1 2 3 4	Licensee agrees to conduct conduct an in-service training with staff to ensure that staff are entering all resident medication information into the Centrally Stored Medication and Destruction Record. Once training is complete, the licensee agrees to submit copies of straff training records to the department by 01/13/2026, including names of staff trained, dates of training, training topics, and names and qualifications of trainers.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC809 (FAS) - (06/04)

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