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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200583
Report Date: 02/25/2022
Date Signed: 03/09/2022 08:36:44 AM

Document Has Been Signed on 03/09/2022 08:36 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:WRC-2FACILITY NUMBER:
445200583
ADMINISTRATOR:MEGAN C. MILLERFACILITY TYPE:
740
ADDRESS:174 WILLOWBROOK DRIVETELEPHONE:
(831) 336-5196
CITY:BEN LOMONDSTATE: CAZIP CODE:
95005
CAPACITY: 6CENSUS: DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Megan MillerTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 02/25/2022 at 10:40am. LPA met with facility Administrator Megan Miller (Admin). LPA toured the facility, including front office, medicine room, kitchen, dining room, living room, 1 bathroom, 2 resident rooms, and back patio.

All staff members observed to be wearing masks. All residents in facility observed to be wearing masks. Admin confirmed that all residents and staff have been vaccinated. Facility Mitigation plan has already been submitted and approved. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility noted to not have N95s stored within the building, they are instead located in WRC-1 across the street.

Facility observed to have designated entry point. Staff took LPA's temperature, and screened for symptoms. Facility bathrooms not noted to have hand washing signs. Facility isolation area noted to not have an area for PPE donning and doffing. Facility only has one staff member working in the facility, who would be interacting with both COVID positive and COVID negative residents.

LPA observed locks on refrigerator and freezer.

Advisory notes were issued. See LIC 9102. Deficiency cited during visit. See LIC 809-D. This report reviewed with Administrator Megan Miller and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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 03/02/2022 02:09 PM - It Cannot Be Edited


Created By: Ryker Heberle On 02/25/2022 at 12:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WRC-2
FACILITY NUMBER: 445200583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87872(a)(3)
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to refrigeration units possessing locks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
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Licensee is to remove locks from food refirgeration and freezer units. Licensee shall provide photo documentation of removed locks to the department by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022


LIC809 (FAS) - (06/04)
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