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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294274
Report Date: 03/15/2024
Date Signed: 03/17/2024 07:46:12 PM


Document Has Been Signed on 03/17/2024 07:46 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: 19DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Anne RoxasTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required annual inspection and met with facility House Manager (HM) Anne Roxas. At the time of the visit Administrator Hong-Gen Chen, personally appeared to inform LPA that she has scheduled appointment and assigned HM as the authorized representative.

The facility's census is 19 resident and 24 staff.

LPA toured the facility, including entryway, common room, dining room, kitchen, laundry room, 4 bedrooms, 3 bathrooms, medicine room, and activity room. LPA toured the exterior of the facility and observed all walkways are free from obstruction.

No prohibited items were observed in the resident rooms and sliding doors were kept in good working condition. All emergency exits are clear from obstruction. The interior hallways and walkways are free from obstruction, LPA tested the door alarms and found it to be in good working condition. Facility has activities scheduled posted for the whole month. LPA observed residents participating during activity time.

LPA tested the facility water temperature. Water temperature measured between 105 to 111.5 degree Fahrenheit. LPA observed sufficient supply of food, 2 days of perishable food and 7 days for non-perishable food. Fire extinguisher was last inspected on 03/13/2024. All toxins are kept in a locked room. Knives are locked and not accessible to residents.

LPA reviewed the facility's fire alarm and generator log. The fire alarms system and generator for the entire building were tested on 2/21/2024. Generator and fire alarm passed inspection.
continued to LIC 809C
page 1 of 2
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 445294274
VISIT DATE: 03/15/2024
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LPA interviewed 2 facility staff. LPA reviewed 4 resident files and 4 staff files and found records to be complete and updated.

LPA reviewed the Centrally Stored Medication and Destruction Report for 4 residents and found all records to be updated.

Disaster training for all staff and resident are up to date.

No deficiency was cited during today's visit per CCR Title 22. This report was reviewed with House Manager Anne Roxas and a copy of the signed report was provided.

End of Report
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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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