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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202914
Report Date: 12/07/2023
Date Signed: 12/07/2023 12:19:51 PM

Document Has Been Signed on 12/07/2023 12:19 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:ALTA HOMEFACILITY NUMBER:
445202914
ADMINISTRATOR:JIMENEZ, ISABELFACILITY TYPE:
735
ADDRESS:21 ALTA DRIVETELEPHONE:
(831) 818-7981
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 4CENSUS: 0DATE:
12/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Isabel JimenezTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted a Pre-Licensing visit and met with Administrator Isabel Jimenez.

During visit, LPA Marrufo toured the inside and outside of the facility. The facility kitchen area had locked cabinets for storing sharps, cleaning supplies, and a first aid kit. 3 out of 3 resident bedrooms had available bedding, working lights, and clothing storage areas. 5 out of 5 smoke detectors and 3 out of 3 carbon monoxide detectors functioned properly when tested. The facility bathroom had available lights, soap, and paper towels, and the shower had guard rails. The sink water temperature measured at 110 F.

The facility garage area had locked storage areas for resident records and medications.

The outdoor area was toured and the exits were found to be clear of obstructions.

During visit, LPA Marrufo reviewed the Component III presentation with Administrator.

No deficiencies were cited at this time as per California Code of Regulations Title 22.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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