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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202902
Report Date: 12/26/2024
Date Signed: 12/26/2024 04:56:10 PM

Document Has Been Signed on 12/26/2024 04:56 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: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: 19DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Hector MarquezTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Hector Marquez, Program Coordinator (PC) and Administrator (ADM) Mauna Morris.

During visit, LPA toured the facility inside and out with PC. 5 clients and 2 staff were observed in the facility. PC stated 9 clients went out with 3 staff.

License, personal rights posters were observed in the facility. The facility restroom had available soap and paper towels. The water temperature was measured at 107 F. The outdoor exit was clear of obstructions.

Fire extinguisher was serviced on 11/25/2024. The facility was equipped with fire alarm system, and carbon monoxide detector. carbon monoxide detector was tested by PC, and was working fine.

LPA requested LIC500. Based on the review of LIC500, LPA did not see staff S1. PC provided the names of the staff at the facility and the staff took clients out, no staff match the name of S1. ADM stated in September 2024, the facility received notice from the Department that S1 is not eligible to work at the facility. ADM stated the facility never hires S1 as employee, and S1 never worked at the facility.

LPA reviewed 5 resident records and 5 staff records. One resident's Appraisal Needs and Service Plan was observed did not update since 2021.

The facility was unable to provide the emergency/fire drill log document.

Deficiencies noted for today's inspection visit. See LIC809-D for more information.

This report was reviewed with PC and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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 2
Document Has Been Signed on 12/26/2024 04:56 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 12/26/2024 at 01:45 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: MOBILE WORK GROUP
FACILITY NUMBER: 445202902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental, psychological, and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the Apprasil Needs and Service Plan of 1 Out of 5 resident files was observed did not update since 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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Administrator stated to send the plan of correction by the POC due date to ensure clients'' Appasil Needs and Service Plan are update at least yearly.
Type B
Section Cited
CCR
82023(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented and the documentation maintained in the day program for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the facility was unable to provide the emergency frill log document which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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Administrator stated to send the plan of correction by the POC due date to ensure the facility maintain the emergency drill document up to 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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
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