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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202946
Report Date: 12/11/2024
Date Signed: 12/11/2024 11:22:01 AM

Document Has Been Signed on 12/11/2024 11:22 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:MAPLE HOUSE IIFACILITY NUMBER:
445202946
ADMINISTRATOR/
DIRECTOR:
ROXAS, ROSE ANNEFACILITY TYPE:
740
ADDRESS:2000 BROMMER STREETTELEPHONE:
(831) 476-6366
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 40CENSUS: DATE:
12/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Anshu GuptaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Marcella Tarin and David Marrufo arrived unannounced to conduct a pre-licensing visit to follow up on corrections and deficiencies that were observed on 10/22/2024 during a previous pre-licensing visit.

On 10/22/2024 during a pre-licensing visit with LPAs Mita Partoza and Marcella Tarin, deficiencies were observed and documented in the Pre-Licensing report. LPAs observed the dishwasher in the kitchen was corroded and 2 parking lot cement stoppers were cracked. The current licensee needed to address that equipment and that the physical plant are in good repair with no breaks, cracks or chips.

On 10/23/2024 the facility submitted pictures of the removal of the parking lot cement stoppers. On 12/11/2024, LPAs observed there were no broken parking lot cement stoppers in the parking lot. LPAs also observed the dishwasher to be free of corrosion. Applicant states the facility is in the process of replacing the current dishwasher with a new one.

LPAs reviewed the Fire Safety Inspection Request dated 11/04/2024, which indicated a capacity for 8 bedridden residents. The LIC200 Application for a Community Care Facility or Residential Care Facility for the Elderly License indicated a bedridden capacity for 15. LPAs advised applicant to re-submit the LIC200 to Centralized Application Bureau (CAB) for the bedridden increase request.

During visit, LPAs reviewed Component III with Applicant Anshu Gupta.

No deficiencies were cited today per California Code of Regulations Title 22. This report was reviewed with Applicant Anshu Gupta and a copy of this report was provided.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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