<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202914
Report Date: 12/27/2024
Date Signed: 12/27/2024 11:56:30 AM

Document Has Been Signed on 12/27/2024 11:56 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:ALTA HOMEFACILITY NUMBER:
445202914
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, ISABELFACILITY TYPE:
735
ADDRESS:21 ALTA DRIVETELEPHONE:
(831) 818-7981
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 4CENSUS: 4DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Isabel Jimenez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 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 Analysts (LPAs) Marcella Tarin and Kenneth Madrigal conducted an unannounced annual inspection and met with Administrator (ADM) Isabel Jimenez. LPAs toured the interior and exterior of the facility with ADM to include the kitchen, office, client rooms, dining room, bathrooms, back and front of the facility. Facility thermostat temperature display was observed at 71 degrees F. All exit and passageways were free and clear of obstruction.

LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the medication storage area, knives storage area were locked and inaccessible to clients in care.

LPAs toured 4 client bedrooms. 4 out of 4 client bedrooms had a bed, functioning lights, dresser/table, a chair, bedding and space for personal belongings. LPAs toured 4 client bathrooms. 2 of 2 client bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPAs observed 2 floor mats in 2 client bathrooms that slid across the floor when stepped on. LPAs advised ADM to purchase non-skid mats that do not slide across the floor when stepped on. LPAs measured water temperature with a range from 111 too 115.5 degrees F in 2 out of 2 client bathrooms.

During tour of the facility's backyard, LPAs observed a wooden fence, with an open area, that did not completely enclose the backyard. LPAs observed the open area of the fence leads to an open field, surrounded by neighboring homes (pictures taken). ADM stated all clients are accompanied by staff when outside. LPAs advised ADM to install a fence or gate to ensure the safety of clients in care. LPAs advised ADM that the facility must be in good repair at all times to ensure the safety of clients.

See LIC809-C
Page 1 of 2.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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
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: ALTA HOME
FACILITY NUMBER: 445202914
VISIT DATE: 12/27/2024
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
26
27
28
29
30
31
32
The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 11/24/2024 2024. LPAs reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 12/15/2024. Drills are being conducted monthly.

LPAs reviewed 4 client records. 4 out of 4 clients records were found to be complete. Client records included emergency contact information, physician’s report, appraisal/needs and service plans, and personal rights.

LPAs reviewed 4 client's Centrally Stored Medication and Destruction Records (CSMDR’s). 4 out of 4 CSMDR’s were observed to be complete with all medication documented.

LPAs reviewed client’s P&I with the ADM. 4 out of 4 client’s P&I records were complete with all money documented accurately.

LPAs reviewed 6 staff records. 6 out of 6 staff records were found to be complete. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record and staff training.

No deficiencies were cited during today's visit. Two Technical Advisory Notes were issued. See LIC 9102 for more information. An exit interview was conducted with ADM Isabel Jimenez and a signed copy of this report was provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2