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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202878
Report Date: 04/02/2025
Date Signed: 04/02/2025 11:09:11 AM

Document Has Been Signed on 04/02/2025 11:09 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: 6DATE:
04/02/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Yuly AritaTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Yuly Arita, Office Manager (OM). The purpose of the visit was to follow up on an incident reported by the facility via Unusual Injury/Incident Report (IR) on 03/21/2025. The IR states that on 03/21/2025 at approximately 3:00 PM, resident R1 left the facility via taxi to go to the post office. The IR states that staff attempted to bring R1 back into the facility, but R1 entered the taxi and left. Staff found R1 at a local post office and returned R1 to the facility at approximately 3:20 PM.

During visit, LPA Marrufo interviewed OM, who stated that R1 left the facility through the front patio door. OM stated that OM normally takes R1 to the post office, but on the day of the incident, OM was busy and was not able to take R1 to the post office. OM stated R1 called the taxi service. OM stated when the taxi service arrived, staff let the taxi driver know that R1 is unable to leave the facility, but the taxi driver took R1 anyway. OM stated the facility has previously contacted the taxi company and informed them that R1 is not able to leave the facility unassisted. OM stated to have assessed R1 upon his/her return to the facility and determined R1 was fine.

During visit, LPA discussed with OM about reminding R1 to not leave to the post office alone and to wait for a staff to take him/her to the post office.

R1's Physician's Report states R1 has dementia and is unable to leave the facility unassisted. R1's Physician's Report states R1 has wandering and sundowning behavior. R1's Appraisal/Needs and Services Plan states R1 has been trying to leave the facility. See LIC809-C page for more information. Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Sarah Yip
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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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Document Has Been Signed on 04/02/2025 11:09 AM - It Cannot Be Edited


Created By: David Marrufo On 04/02/2025 at 10:25 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: EASTLAKE VILLA HOME CARE
FACILITY NUMBER: 445202878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/03/2025
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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Licensee agrees to submit a Plan of Correction by POC date detailing how the facility will ensure that residents, particularly resident R1, does not leave the facility unassisted. The plan should include how the facility will communicate with the taxi company that R1 is unable to leave the facility
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(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 left the facility unassisted, which poses an immediate safety risk to residents in care.
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unassisted, reminding R1 that he/she is unable to leave the facility unassisted, coordinating with R1 to have a staff take R1 to the post office, and instructing staff on what to do if a taxi comes to pick up a resident with dementia.

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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.
Sarah Yip
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


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: EASTLAKE VILLA HOME CARE
FACILITY NUMBER: 445202878
VISIT DATE: 04/02/2025
NARRATIVE
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During visit, LPA Marrufo conducted a health and wellness check with R1. LPA observed that the front patio door alarm was triggered when the door was opened.

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

This report was reviewed with OM Yuly Arita and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Sarah Yip
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
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