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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294215
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:24:25 PM


Document Has Been Signed on 06/21/2022 04:24 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: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:
06/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Haydee SatoTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management visit and met with Licensee, Haydee Sato.

The purpose of the visit was to ensure the facility has sufficient staffing and supplies to meet the needs of persons in care. Licensee stated to not be sure whether the facility will be closing down operation.

During visit, LPA toured the two buildings of the facility to include the kitchen, living room, bathrooms, and resident rooms. LPA observed 3 staff members working. Fire exit routes were free and clear of obstruction. Facility has 2 days worth of perishable foods and 7 days worth of non-perishable foods. The facility restocked on their food supply on Saturday, 06/18/222. LPA observed an adequate supply of personal care and hygiene products for the residents. Licensee stated the residents would supply their own hygiene products or the facility will supply the hygiene products, if needed. Licensee stated the facility has enough funding for the month to provide food, essential supplies and services to the residents.

The facility temperature was maintained at 89 degrees Fahrenheit. The outside temperature was at 97 degrees Fahrenheit. Licensee stated the central AC system is in disrepair. LPA observed the facility's doors and windows to be open, fans located in the living room, and fans inside the resident rooms.
LPA obtained the facility's LIC500, resident roster, and residents emergency contact information. Licensee will email LPA the facility's monthly operating cost and resident's diagnosis and ambulatory status by 06/22/2022. Licensee is informed of the scheduled virtual meeting with the Department on 06/23/2022.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D.

An exit interview conducted. This report was reviewed with the Administrator and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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Document Has Been Signed on 06/21/2022 04:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited

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87303 Maintenance and Operations (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement is not met as evidenced by:
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Based on observation and interview, the facility temperature was maintained at 89 degrees Fahrenheit during a 97 degree Fahrenheit day which poses an immediate health, safety, and personal rights risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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