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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600460
Report Date: 08/10/2023
Date Signed: 08/10/2023 11:13:00 AM

Document Has Been Signed on 08/10/2023 11:13 AM - 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MONTEBELLO HOMEFACILITY NUMBER:
198600460
ADMINISTRATOR:OBSTACULO, CRISTINAFACILITY TYPE:
735
ADDRESS:740 SOUTH MONTEBELLO BLVD.TELEPHONE:
(323) 477-1543
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY: 6CENSUS: 6DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Cristina ObstaculoTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Caregiver Manuel Suyat and explained the reason for the visit. Shortly thereafter Administrator Cristina Obstaculo arrived. The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Caregiver Manuel Suyat today 08/10/2023 at 8:45 AM and the following was observed
Facility contains 3 Client Bedrooms and 2 client bathrooms dining room, kitchen, and TV room.
Hot water temperature measured between 105 F. and 120 F. meeting Title 22 Regulations.
Required Annual Inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Training, Client Rights- Information, Client Records- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster preparedness, and Emergency Intervention.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables. All staff were cleared and associated.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained. Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Medication was reviewed and was given per physician's directions. 4 Client Files and 3 Staff Files were reviewed.
Interviews were conducted with 2 Staff and 1 client. 3 client's were at day program, 1 refused to be interviewed and 1 is in the hospital.
Bathtub contains mold around basin, water faucet knob broken off, and window screen torn in client's room.
Backyard area cluttered with mattress, beds, chairs and table.

Deficiencies cited on 809 D. Exit interview conducted and copy provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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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Document Has Been Signed on 08/10/2023 11:13 AM - It Cannot Be Edited


Created By: Glenn Trueman On 08/10/2023 at 10:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MONTEBELLO HOME
FACILITY NUMBER: 198600460

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with bathtub containing mold around basin, water faucet knob broken off, and window screen torn in client's room. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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Facility to make necessary repairs by POC due date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above with backyard area cluttered with mattress, beds, chairs and table which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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Backyard area cleared of clutter.
Correction cleared at visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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