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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202947
Report Date: 08/07/2024
Date Signed: 08/07/2024 02:53:39 PM


Document Has Been Signed on 08/07/2024 02:53 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MAPLE HOUSE, THEFACILITY NUMBER:
445202947
ADMINISTRATOR:LISING, RONNIEFACILITY TYPE:
740
ADDRESS:410 PENNSYLVANIA AVENUETELEPHONE:
(831) 423-6347
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:22CENSUS: 13DATE:
08/07/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Ronnie LisingTIME COMPLETED:
01:59 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced pre-licensing inspection visit and met with Administrator (ADM) Ronnie Lising.

LPA observed 4 staff and 13 residents in the facility. LPA toured the facility inside out with ADM. Personal Rights posters and Administrator Certificate were observed in the facility. Living room, dining room, kitchen, 11 resident bedrooms, 8 restrooms, 2 common bathrooms, two storage rooms, laundry room, sun room, and 1 office were inspected.

Two day perishable food supplies and Seven day nonperishable food supplies were observed sufficient. The temperature of the refrigerator is at 40 degree F and the temperature of the freezer is at 0 degree F. Room temperature was observed at 73 degree F. Hot water temperature was observed at 109 degree F. All the bedrooms were observed with window screens.

Fire extinguisher was serviced on 05/128/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Emergency light system was observed in the facility. Call button system was observed in the facility, and was tested by ADM and was working fine. Medications closet was observed locked. Knives closet and detergent closet were observed locked. Night lights were observed at the hallway. First aid box and flash lights were observed in the facility. Bars and non skid mats were observed in the restrooms and common bathrooms. Door alarm was observed at the entrance door.

LPA toured the backyard with ADM. Three storage rooms were observed at the backyard. two gate alarms were observed at the two exit gates. No obstruction were observed to block the walkway. Component II was conducted with ADM.No deficiency noted today. Exit interview was conducted with ADM. The report was provided to ADM for signatures. a copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
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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