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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294215
Report Date: 06/30/2022
Date Signed: 07/01/2022 09:35:31 AM


Document Has Been Signed on 07/01/2022 09:35 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
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:
06/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Myla IlaganTIME COMPLETED:
03:47 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 06/30/2022 at 02:59pm. LPA met with facility temporary Administrator Myla Ilagan(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 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 2 days of perishable food and 1 weeks worth of non-perishable food. Facility temperature observed to be maintained at 72 *F. Facility water temperature measured at 105.3*F.

Facility observed to have designated entry point. Staff took LPA's temperature, and screened for symptoms upon entry. All bathrooms observed to have paper towels, lidded trash cans, and handwashing signs posted.

LPA spoke with prospective licensee Rachelle Recinto via telephone. LPA reminded prospective licensee to provide licensing with a lease backed agreement and to update the responsible party informational letter to include additional information regarding the responsibilities and updated structure of the change of ownership. No deficiencies cited during visit. This report reviewed with temporary Administrator Myla Ilagan 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: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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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