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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202902
Report Date: 07/12/2024
Date Signed: 07/12/2024 11:52:30 AM

Document Has Been Signed on 07/12/2024 11:52 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:MOBILE WORK GROUPFACILITY NUMBER:
445202902
ADMINISTRATOR/
DIRECTOR:		MORRIS, MAUNAFACILITY TYPE:
775
ADDRESS:1062 SOUTH GREEN VALLEY RDTELEPHONE:
(831) 728-0321
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 28CENSUS: 18DATE:
07/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Hector MarquezTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Hector Marquez, Program Coordinator.

During visit, LPA Marrufo toured the facility inside and out. The facility bathroom had available soap and paper towels. The water temperature in the bathroom sink measured at 110 F. The outdoor exit was clear of obstructions.

LPA reviewed 5 resident records and 5 staff records. Resident R1's record was missing an Admission Agreement. Staff S1 was missing a current first aid certification. Staff S2's record was missing an LIC9052 Employee Rights form. Staff S3 was missing an LIC503 Health Screening form. Staff S4's record was missing an LIC501 Personnel Record and an LIC9052 Employee Rights form.

The last documented Emergency Disaster Drill was conducted on 06/10/2024. During visit, staff stated to not have any record of the last smoke detector test.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information. Advisory Notes were issued. See LIC9102 for more information.

This report was reviewed with Hector Marquez and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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Document Has Been Signed on 07/12/2024 11:52 AM - It Cannot Be Edited


Created By: David Marrufo On 07/12/2024 at 11:31 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: MOBILE WORK GROUP
FACILITY NUMBER: 445202902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(6)
80070 Client Records (b) Each record must contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 80068.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 1 out of 5 reviewed resident records, as evidenced by 1 out of 5 resident records did not include an Admission Agreement, which poses a potential personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Licensee agrees to submit a copy of resident R1's Admission Agreement to CCL by POC date.
Type B
Section Cited
CCR
80066(a)(10)
80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 1 out of 5 reviewed staff records, as evidenced by 1 out of 5 staff records did not include a health screening form, which poses a potential health risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Licensee agrees to submit a copy of staff S3's Health Screening form to CCL by POC date.
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: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
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