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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200315
Report Date: 12/07/2021
Date Signed: 12/07/2021 01:38:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MONTESSORI SENIOR RESIDENTIAL CAREFACILITY NUMBER:
079200315
ADMINISTRATOR:PAMELA ZELL RIGGFACILITY TYPE:
740
ADDRESS:3431 BALFOUR ROADTELEPHONE:
(925) 516-2111
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 4DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Shaku ChhaganTIME COMPLETED:
02:00 PM
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On 12/7/2021 at 11:25AM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with staff Ruth Cabral. LPA observed 4 residents during the visit. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. LPA observed pool was fenced and inaccessible to residents in care. Administrator assistant Shaku Chhagan arrived around 12:25PM and LPA explained the purpose of the visit.

Infection control designated leader is staff Ruth Cabral and Assistant Administrator Shaku C. . There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 72 degrees Fahrenheit. Smoke and Carbon monoxide detectors were operational.



Continued on next page LIC 809-C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MONTESSORI SENIOR RESIDENTIAL CARE
FACILITY NUMBER: 079200315
VISIT DATE: 12/07/2021
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LPA observed the following:

· Facility DOES NOT document daily COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility.

· A sign in policy is NOT enacted with all visitors, facility was only screening for temperature check and not the other covid19 symptoms, LPA provided technical assistance.

· Signs are NOT posted at the facility entrance with updates of visitor policy.

· Facility DO NOT have adequate 30-day supply of PPE (e.g., face masks, respirators, gowns, gloves, and eye protection such as face shield or goggles).

· Licensee has NOT provided staff N95 FIT testing for all staff. LPA provided technical assistance to Assistant Administrator.

· PPE is NOT stored in once location. LPA provided technical assistance to Assistant Administrator and discussed the importance of having one organized location for all PPE supplies.


Proof of corrections were discussed with Shaku Chhagan.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC809 (FAS) - (06/04)
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