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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294274
Report Date: 10/22/2024
Date Signed: 10/22/2024 02:02:06 PM


Document Has Been Signed on 10/22/2024 02:02 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: 21DATE:
10/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rose Anne Roxas, Designated AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Marcella Tarin and Maria (Mita) Partoza arrived unannounced to conduct the facility's pre-licensing visit for a change of ownership (CHOW). LPAs met with Rose Anne Roxas, Designated Administrator. Licensee/Administrator Hong-Gen (Sara) Chen was unavailable at the time of the visit.

LPAs observed the dishwasher in the kitchen was corroded and 2 parking lot cement stoppers were cracked and posed a tripping hazard. Current licensee needs to address equipment and ensure that the physical plant is in good repair with no breaks, cracks or chips prior to issuing license to new owner.

A deficiency was issued per California Code of Regulations Title 22. See LIC809D. An exit interview was conducted with Rose Anne Roxas, Designated Administrator, and a copy of this report was provided and appeal rights were provided.
SUPERVISOR'S NAME: Jin JackieTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella TarinTELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024
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


Document Has Been Signed on 10/22/2024 02:02 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: MAPLE HOUSE II, THE
FACILITY NUMBER: 445294274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
87303(a)

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87303(a) The facility shall be... safe... and in good repair at all times. Maintenance shall include... the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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ADM stated the repairs will addressed by replacing one of the cement stoppers and removing the second cement stopper, making it a 'no parking' area. POC will be submitted by POC due date 10/23/2024.
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Based on observation the licensee did not keep the facility in good repair by not addressing the 2 cracked cement parking stoppers, which is a tripping hazard to residents, visitors and staff, which posed/poses an immediate health, safety and personal rights risk 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: Jin JackieTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella TarinTELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024
LIC809 (FAS) - (06/04)
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