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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200583
Report Date: 06/28/2024
Date Signed: 06/28/2024 02:11:02 PM

Document Has Been Signed on 06/28/2024 02:11 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:WRC-2FACILITY NUMBER:
445200583
ADMINISTRATOR/
DIRECTOR:
MEGAN C. MILLERFACILITY TYPE:
740
ADDRESS:174 WILLOWBROOK DRIVETELEPHONE:
(831) 336-5196
CITY:BEN LOMONDSTATE: CAZIP CODE:
95005
CAPACITY: 6CENSUS: 5DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator, Megan MillerTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Megan Miller. LPA Rai observed 1 staff (S1) and 4 residents at the facility. During the visit, 1 residents was out of the facility. The residents at this facility are overseen by Santa Cruz County Behavioral Health.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the resident bedrooms. 4 Out of 4 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 109.7 degrees F - 110.7 degrees F. The water temperature in the kitchen sink was 111.7 degrees F. Fire extinguisher was observed and inspected on 5/30/2024. Facility smoke detectors and carbon monoxide detectors are in working condition. The last two disaster drill conducted were on 4/18/2024 and 5/20/2024.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records. LPA Rai reviewed resident's LIC 405 Record of Resident's Safeguarded Cash Resources. No issues or concerns were observed.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM) Megan Miller and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
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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