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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610040
Report Date: 12/06/2022
Date Signed: 12/06/2022 01:53:35 PM

Document Has Been Signed on 12/06/2022 01:53 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 CANYON 2FACILITY NUMBER:
197610040
ADMINISTRATOR:ALEXANDRA DECLEENEFACILITY TYPE:
772
ADDRESS:2890 KANAN DUME RDTELEPHONE:
(203) 823-8588
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY: 10CENSUS: 9DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chelsea RosemanTIME 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 Residential Manager, Chelsea Roseman and explained the reason for the visit.

At approximately 10:15am, with the assistance of the Residential Manager, LPA took a tour of the physical plant. The facility is a three level building. There is one (1) bedroom at the lower level, three (3) bedrooms on the main level, and one (1) bedroom in the upper level. Required postings were observed and temperature check was made at the entry area, located in the main level. The smoke alarms are hardwired and interconnected. There are carbon monoxide detectors on site that functions properly. There are fire extinguishers located throughout the facility. The charge date for the fire extinguishers 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. LPA did not observe any knives or sharp objects accessible to the clients in care. Emergency food supply is stored in the garage.

Bedrooms: There were five (5) bedrooms designated for residents' use. All five bedrooms are shared rooms. They were all observed to be properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are six (6) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 110 and 120 degrees Fahrenheit.

Common Areas: Common areas include the living room and dining area. The facility also has one (1) group room and four (4) therapy rooms. These rooms were properly furnished.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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 2
FACILITY NUMBER: 197610040
VISIT DATE: 12/06/2022
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The backyard had a swimming pool that was gated and locked with a five foot fence. The outdoor area was free of hazards. The laundry area is located in the garage.

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 at the center hallway on the main level. Medication storage and records were reviewed. The medication room also maintains first aid kits and four emergency supply backpacks.

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: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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