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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603023
Report Date: 05/10/2024
Date Signed: 05/10/2024 12:36:37 PM

Document Has Been Signed on 05/10/2024 12:36 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:MONTIANO RESIDENTIAL CAREFACILITY NUMBER:
198603023
ADMINISTRATOR/
DIRECTOR:		MARTINE, CLARELFACILITY TYPE:
735
ADDRESS:1022 W FLORENCE AVETELEPHONE:
(323) 758-9539
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 24CENSUS: 21DATE:
05/10/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Clarel MartineTIME VISIT/
INSPECTION COMPLETED:
12:36 PM
NARRATIVE
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On 05/10/2024, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Clarel Martine, and the purpose of today’s visit was explained. The facility is licensed to operate for (24) ambulatory adults ages 18 through 59. Currently, the home has (21) clients.

The facility is a one-story home located in a residential neighborhood. The property consists of the following: (12 ) client bedrooms, (4 ) bathrooms, (1)living room, kitchen, dining room, and an outdoor patio shaded area.

At PM LPA Watson toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were inspected. Adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were inspected. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were inspected. Toilets and water faucets worked. Shower was free of mold/mildew. Toiletries were accessible to clients. The water temperature measured between (73.5 F) to (144.1 F) in the bathrooms and kitchen.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: MONTIANO RESIDENTIAL CARE
FACILITY NUMBER: 198603023
VISIT DATE: 05/10/2024
NARRATIVE
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. (14 ) smoke detectors and carbon monoxide detector were observed. Fire extinguishers were fully charged, toxins and knifes were inspected. Medications were accounted for, centrally stored, and properly locked. The first aid kit was checked and fully stocked with the correct authorized manual. Outside grounds were toured and no bodies of water were observed. Exits/walkways around the home were observed.

During today’s visit LPA observed deficiencies.

LPA conducted a records review of (10 ) client records, (3) staff records and reviewed the facility disaster plan. All client & staff records were a physician’s report and (TB) tuberculosis test results. The facility disaster plan was current and in compliance with Title 22 at the time of visit.

Exit interview conducted with the House Manager Michael Martinez and a copy of the report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 05/10/2024 12:36 PM - It Cannot Be Edited


Created By: Troy Watson On 05/10/2024 at 10:36 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTIANO RESIDENTIAL CARE
FACILITY NUMBER: 198603023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)(2)(A)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:  (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary.  These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator to clean all bedroom wall, floors,bedding etc. soiled with urine etc. in order to ensure the cleanliness of the facility and health safety of the residents. Adminstrator must submit proof of cleaning via email or by fax on or before 05/31/2024.
Type B
Section Cited
CCR
85095.5(a)(2)(C)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:  (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (C) Spills of blood and other potentially infectious materials and surfaces shall be promptly cleaned and disinfected. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator to make sure that infection control practices are maintained throughout the facility by providing hand sanitizer soap, masks, gloves etc. as needed. Adminstrator must submit proof of cleaning via email or by fax on or before 05/31/2024.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Troy Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 05/10/2024 12:36 PM - It Cannot Be Edited


Created By: Troy Watson On 05/10/2024 at 10:36 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTIANO RESIDENTIAL CARE
FACILITY NUMBER: 198603023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80021(a)(2)
Water Supply Clearance
(2) Subsequent to initial licensure, the licensee shall provide evidence of a bacteriological analysis of the private water supply as frequently as is necessary to ensure the safety of the clients, but no less frequently than specified in the following table:
For a licensed capacity of 6 or fewer analysis is required at initial licensing and subsequent analysis is not required unless evidence supports the need for such analysis to protect clients.
For a licensed capacity of 7 through 15 analysis is required at initial licensing and subsequent analysis is required annually.
For a licensed capacity of 16 through 24 analysis is required at initial licensing and subsequent analysis is required semiannually.
For a licensed capacity of 25 or more analysis is required at initial licensing and subsequent analysis is required quarterly.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator to submit proof of bacteriological analysis via email or by fax on or before 05/31/2024.

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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Troy Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 05/10/2024 12:36 PM - It Cannot Be Edited


Created By: Troy Watson On 05/10/2024 at 10:36 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTIANO RESIDENTIAL CARE
FACILITY NUMBER: 198603023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

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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2
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator to clean all bathrooms, and hallways to ensure the cleanliness of the facility and health safety of the residents. Adminstrator must submit proof of cleaning via email or by fax on or before 05/31/2024.
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator to remove all outside trash, shopping carts, broken glass, and decaying garbage next to the facility walls and premises and make outside passage ways fee from obstruction, in order to ensure the cleanliness of the facility and health safety of the residents. Adminstrator must submit proof of cleaning via email or by fax on or before 05/31/2024.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Troy Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 05/10/2024 12:36 PM - It Cannot Be Edited


Created By: Troy Watson On 05/10/2024 at 10:36 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTIANO RESIDENTIAL CARE
FACILITY NUMBER: 198603023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(b)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator to replace all smoke detectors that are in - operable withing the facility in order to ensure the safety of the of the residents in case of a fire hazard and potential harm to residents. Adminstrator must submit proof of operational smoke alarms via email or by fax on or before 05/31/2024.
Type B
Section Cited
CCR
80087(b)(1)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator to ensure that there are rugs and non-slip material within showers, bathrooms and walkways, please submit proof of correct via email or by fax on or before 05/31/2024.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Troy Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 05/10/2024 12:36 PM - It Cannot Be Edited


Created By: Troy Watson On 05/10/2024 at 10:36 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTIANO RESIDENTIAL CARE
FACILITY NUMBER: 198603023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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2
3
4
Administrator to submit proof of facility in good repair both inside and outside the premises, free of insects, dirt, and other debris from pets etc. in the living room, dining area, kitchen, hallways and bathroom.
Type B
Section Cited
CCR
80088(e)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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2
3
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Administrator to submit proof of fron porch furniture, patio furniture, and living room furniture in good repair and free of insects, dirt and other debris from pets etc in the living room, dining area, kitchen, hallways and bathroom. Bathroom to deliver hot water between the mandated temperatures of m105F and 120F. Administrator to submit proof of correction via fax or email by 05/31/2024.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Troy Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 05/10/2024 12:36 PM - It Cannot Be Edited


Created By: Troy Watson On 05/10/2024 at 10:36 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTIANO RESIDENTIAL CARE
FACILITY NUMBER: 198603023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
Administrator to submit proof of water temperature registering between 105 degrees F and no more than 120 degrees F, and submit proof via email or fax by 05/17/2024.
Type B
Section Cited
CCR
80088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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2
3
4
Administrator to submit proof of repair to leaking kitchen pipe, and proof of repair to broken leaking wash basin in resident bathroom located at the back of the facility and submit proof of correction via email or fax by 05/17/2024.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Troy Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 05/10/2024 12:36 PM - It Cannot Be Edited


Created By: Troy Watson On 05/10/2024 at 10:36 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTIANO RESIDENTIAL CARE
FACILITY NUMBER: 198603023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
1
2
3
4
Administrator to submit proof of sanitary cleanliness inside of bathroom floors, walls, toilets and sinks via email or fax by 05/31/2024.
Type B
Section Cited
CCR
80088(f)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
1
2
3
4
Administrator to get rid of foul odor and by properly cleaning and disinfecting facility and exposing of trash and debri both inside and outside of the facility on a daily basis. Please submit proof of sanitary cleanliness free of foul odo via email or fax by 05/31/2024.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Troy Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 05/10/2024 12:36 PM - It Cannot Be Edited


Created By: Troy Watson On 05/10/2024 at 10:36 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MONTIANO RESIDENTIAL CARE
FACILITY NUMBER: 198603023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(g)
Fixtures, Furniture, Equipment, and Supplies
(g) The licensee shall provide linens of various kinds necessary to meet the program of services being offered by the facility and the requirements specified in Chapters 2 through 7.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
1
2
3
4
Administrator to submit proof of clean and or fresh bedding, pillows, linen and sanitary cleanliness inside of bedrooms for each client free of hoarding elements such as outside debris and soiled linen and clothing pile on floors or inside closets, Administrator must show proof of cleanliness and correction via email or fax by 05/31/2024.
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator to submit proof of repair to furniture, and provision of clean linen to residents by 05/31/2024 via email or fax by 05/31/2024.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Troy Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
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