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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294274
Report Date: 05/08/2024
Date Signed: 05/08/2024 12:06:43 PM


Document Has Been Signed on 05/08/2024 12:06 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MAPLE HOUSE II, THEFACILITY NUMBER:
445294274
ADMINISTRATOR:CHEN, HONG-GENFACILITY TYPE:
740
ADDRESS:2000 BROMMER STREETTELEPHONE:
(831) 476-6366
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:40CENSUS: 18DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rose Ann Roxas - House ManagerTIME COMPLETED:
12:00 PM
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On 5/8/2024 - LIcensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management visit. LPA stated the purpose of the visit and met with house manager (HM) Rose Ann Roxas.

The purpose of the visit is to address a self-reported a complaint by the facility that a staff was rough and rude to the resident.

During the visit, LPA toured the facility with HM, including but not limited to the staff area, dining area, resident's room, kitchen, activity room, living room and outside perimeter of the facility.

LPA interviewed 5 out of 18 residents (R1 to R5) and 3 staff (S1 to S3). LPA requested documents such as Physician's Report, Resident Roster, Appraisal Needs and Services Plan, Staff Roster, Communication documentation.

This case management will remain open and will require further investigation. No deficiency is cited during today's visit. An exit interview was conducted with House Manager (HM) Rose Ann Roxas.

end of report
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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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