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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200333
Report Date: 12/29/2022
Date Signed: 12/30/2022 09:26:39 AM

Document Has Been Signed on 12/30/2022 09:26 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MANTE BOARD & CARE HOMEFACILITY NUMBER:
275200333
ADMINISTRATOR:SAMSON Z. MANTEFACILITY TYPE:
735
ADDRESS:1553 CUPERTINO WAYTELEPHONE:
(831) 229-4819
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 6CENSUS: 3DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Licensee, Julia ManteTIME COMPLETED:
03:00 PM
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Licensing Program Analyst(LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee Julia Mante, Continual Administrator's Certification expires 07/07/2023. There are currently 3 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 119 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA Hurt confirmed all staff present is background cleared.

LPA Hurt reviewed documents reflecting two of the three residents (Resident 1 and Resident 2) are over the age of 60. LPA Hurt reviewed documents reflecting the residents over 60 do not have needs and service plans updated yearly.

LPA Hurt observed the facilities oven to be broken, and held closed using tape.

No deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610 the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee Julia Mante and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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