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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610039
Report Date: 11/29/2022
Date Signed: 11/29/2022 12:34:05 PM

Document Has Been Signed on 11/29/2022 12:34 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MONTARE AT THE CANYONFACILITY NUMBER:
197610039
ADMINISTRATOR:TIFFANY DZIOBAFACILITY TYPE:
772
ADDRESS:2900 KANAN DUME ROADTELEPHONE:
(203) 823-8588
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY: 6CENSUS: 6DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Erin ThorleyTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Erin Thorley and explained the reason for the visit.

At approximately 10:15am, with the assistance of staff, LPA took a tour of the physical plant. The facility is a two story building with three (3) shared bedrooms and four (4) full bathrooms. Required postings, sign- in sheet and temperature check was observed at the entry area. The smoke alarms are hardwired and battery operated. The carbon monoxide detector is located in the kitchen. There are fire extinguishers located throughout the building, on the first and second floor. The charge date is 8/3/2022.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. There were no knives or hazardous items observed in the open. They were kept locked in a drawer. Cleaning supplies were also maintained in a locked storage. were stored in a locked drawer in the kitchen.

Bedrooms: There were three (3) bedrooms designated for residents' use. One bedroom is on the first floor, and the other two were on the second. Each bedroom is properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are four (4) full bathrooms designated for the residents' use. The were all properly supplied and had functional fixtures. Hot water temperature was measured between 108 and 120 degrees Fahrenheit. No cleaning supplies were observed in the open.

Common Areas: These included the living room, dining area, activity room, exercise room and group room. The common areas were properly furnished. There was a pool table in the activity room. The exercise room is located at the side of the home next to the laundry room. It is accessible to the residents to use with close supervision.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MONTARE AT THE CANYON
FACILITY NUMBER: 197610039
VISIT DATE: 11/29/2022
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Surrounding Grounds: Entry/exits, front and backyards were free of obstruction. There were patio furniture appropriate for outdoor use. The laundry area is located at the side of the home next to the exercise room. Residents do have access to utilize the laundry room to wash their own clothes. There is a swimming pool in the backyard for the residents to use. It was observed with a five foot fence around it's parameters, locked and inaccessible to residents when they're not supervised. The outdoor area was free of hazards.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: The medication room is located on the second floor. Medication and Medication Records were reviewed for proper storage and documentation. The medication room was observed to have first aid kits and emergency supplies.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit.

Exit Interview Conducted and a copy of this report issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2