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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294215
Report Date: 06/25/2021
Date Signed: 07/21/2021 09:23:19 AM

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:SOQUEL LEISURE VILLA, INC.FACILITY NUMBER:
445294215
ADMINISTRATOR:SATO, RENE & HAYDEEFACILITY TYPE:
740
ADDRESS:4101 FAIRWAY DRIVETELEPHONE:
(831) 462-4101
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY:30CENSUS: 17DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Haydee SatoTIME COMPLETED:
04:15 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 06/25/2021 at 02:16pm. LPA met with facility Administrator Haydee Sato (Admin).

LPA toured the facility, including 2 living rooms, 2 dining rooms, kitchen, medicine cabinet, 18 resident rooms, 10 bathrooms, front terrace, and laundry room. Facility observed to have central entry point with hand sanitizer and thermometer.

All staff members observed to be wearing masks. No residents in facility observed to be wearing masks. Admin confirmed that all but 2 residents and 2 staff members have been vaccinated. LPA reminded Administrator to ensure that residents wear masks as much as possible when in common areas of facility. Social distancing signs not posted in all common areas of facility. LPA reminded Administrator to post social distancing signs. No prohibited items noted to be in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility observed to have possession of 30-day supply of PPE.

Facility observed to have designated entry point. Staff took LPA's temperature, and screened for symptoms upon entry. 1 public restroom was observed to not be stocked with paper towels. Hand washing signs observed in all public bathrooms. LPA reminded Admin to stock bathrooms with paper towels.

Advisory notes were issued. See LIC 9102. No deficiencies cited during visit. This report reviewed with Administrator Haydee Sato and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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