445203000-4-9-2026-26-AS-MTAN-DSYQZK-20260409123653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445203000
Report Date: 04/09/2026
Date Signed: 04/09/2026 12:37:14 PM

Document Has Been Signed on 04/09/2026 12:37 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:	MARIPOSA.SC740.LLC		FACILITY NUMBER:	445203000
ADMINISTRATOR/ DIRECTOR:	CASTRO, CARLOS		FACILITY TYPE:	740
ADDRESS:	740 17TH AVE		TELEPHONE:	(831) 313-8155
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY: 14		CENSUS: 0	DATE:	04/09/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Applicant Carlos Castro		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Marcella Tarin conducted an announced pre-licensing inspection. LPA met with Applicant Carlos Castro. LPA stated the purpose of the visit. During visit, LPA toured the inside and outside of the facility to include the kitchen, dining, living room, 10 residents rooms, back and front of the facility. The facility has cameras located in the facility common areas and exterior of the facility. No bodies of water were observed. Facility temperature maintained at 69 F. LPA observed the facility to be clean, safe, sanitary and in good repair. Based on the facility fire clearance, the facility is approved for a capacity of 14, with 13 NON-AMBULATORY of which 1 may be BEDRIDDEN. Bedridden or non-ambulatory residents can occupy the following rooms: 1, 4, 6, 7, 8, 9, 10. All exit and passage ways were free and clear of obstruction. LPA observed a nonperishable food supply of 7 days and a perishable food supply of 2 days. LPA observed sharp supplies in a locked box in the kitchen. Fire extinguisher was inspected on 8/4/2025. The facility fire protection system was inspected on 11/26/2025 by a third party agency and passed inspection. The fire protection system functioned properly when tested by the Applicant. LPA observed medications would locked in a hallway closet inaccessible to residents in care. LPA toured 10 Resident bedrooms. LPA observed Bedroom 1 to have personal belongings. Applicant stated he was currently residing in the room. Bedrooms 1, 4, 6, 7, 8, 9 and 10 have an exit doorway leading out to the exterior of the facility. LPA observed in Bedrooms 9 and 10, the light flickered when turned on. Page 1 of 3

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: MARIPOSA.SC740.LLC	FACILITY NUMBER: 445203000
	VISIT DATE: 04/09/2026

NARRATIVE

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Applicant stated he would replace the light fixtures to ensure they are working properly and not flicker. The facility does not have any staff bedrooms.

LPA toured resident bathrooms and observed the bathrooms to have functioning lights, covered trash bins, and hand soap. LPA measured water temperature in 10 resident bathrooms with a range from 73.4 F to 109 F (1 bathroom water temperature reached 109 F briefly-Bathroom #2). LPA advised Applicant to have the facility water heaters inspected due to the water temperature not within range from 105 F to 120 F (87303 Maintenance and Operation). Applicant stated understanding and would have the water heaters inspected.

LPA observed the facility's laundry room with a washer, dryer. The laundry room is locked and inaccessible to residents in care. The laundry room is located across from Bedrooms 5 and 6. LPA also observed toxins secured in locked cabinets in the laundry room.

LPA did not observe the following posters to include the Licensing Complaint Poster, emergency telephone numbers, personal rights, resident council rights and facility sketch. LPA advised Applicant to ensure the above mentioned posters were posted in the facility as noted in HSC.1569.33(h)(2), HSC1569.267, and HSC1569.157. Licensee stated understanding.

LPA observed monitoring devices are in place at the facility front and back door, which play an auditory sound when a facility door is opened, which can be heard throughout the facility. Applicant stated he would be installing additional alarms on all facility doors that play an auditory sound when opened.

LPA observed the facility to have 2 locked (keypad) exterior perimeter gates. LPA advised Applicant that the 2 locked exterior perimeter gates were a safety concern, and the keypads needed to be removed. Licensee stated understanding, and stated he would remove the keypads and ensure the perimeter gates were not locked. LPA advised Applicant perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. Applicant stated understanding.

LPA observed dark spots on the ceiling in the facility kitchen pantry. Applicant stated he would have the area cleaned.

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NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC809 (FAS) - (06/04)

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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: MARIPOSA.SC740.LLC	FACILITY NUMBER: 445203000
	VISIT DATE: 04/09/2026

NARRATIVE

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LPA observed 2 sheds on the side of the facility. The sheds were locked and inaccessible to residents in care. Applicant unlocked sheds and LPA observed gardening supplies in the sheds.

LPA also observed wooden pallets, granite tiles, gardening supplies and buckets in the facility backyard. Applicant stated these items were going to be removed, placed in the sheds or thrown away.

Applicant states he will be using his personal vehicle to transport residents, until additional vehicles are purchased.

Pre-Licensing is incomplete with corrections to be resolved by 4/24/2026.

A follow up Pre-licensure LIC809 will be generated upon resolution of corrections.

Areas of corrections were discussed during today's visit with the applicant, which included the facility physical plant.

No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted with Applicant Carlos Castro and a copy of this report was provided.

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END OF REPORT

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC809 (FAS) - (06/04)

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