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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
275202407
Report Date:
06/12/2024
Date Signed:
06/19/2024 12:09:44 AM
Document Has Been Signed on
06/19/2024 12:09 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:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
ADMINISTRATOR/
DIRECTOR:
EMMANUEL & JENNIFER INNEH
FACILITY TYPE:
735
ADDRESS:
1100 CARSON STREET
TELEPHONE:
(831) 920-1796
CITY:
SEASIDE
STATE:
CA
ZIP CODE:
93955
CAPACITY:
22
CENSUS:
15
DATE:
06/12/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:
Staff Larry Rimas
TIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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On 6/12/24 Licensing Program Analysts (LPAs) B. Miranda & S. Doucette arrived to the facility unannounced to conduct an annual inspection. LPAs were greeted and allowed entry into the facility. Administrator- Emmanuel Inneh was contacted via phone and was not able to attend the inspection. Staff Larry Rimas conducted the tour with the LPAs and will be signing the report.
LPAs toured the facility inside and out.
Administrator provided report from smoke detectors being tested
and passing. Carbon monoxide readers were not in working order. Areas of the facility needs to be clean. LPA observed kitchen to be cluttered unclean. Cabinets where clean pans and dishes are stored have debris & buildup. Tools are kept unlocked and accessible to residents where the pots & pans are stored.
LPAs observed couches in the facility to be torn and couches in the smoking area have holes and are ducted taped.
LPAs observed fecal matter to be on the floor in one of the men's bathroom.
LPAs observed water temperature in a women's bathroom to read at 123.4 degrees. Hot water was originally turned off in the women's bathroom.
LPAs observed multiple bedrooms with broken blinds, screens torn, and screen door leading to the back is also torn.
LPAs observed a container on the outside of the house being used for drainage to have build-up on and around the surrounding area.
LPAs observed an unused washing machine in the smoking area.
LPAs observed multiple knives, scissors and lighters in kitchen drawers unlocked and accessible to residents.
SUPERVISORS NAME
:
Brenda Chan
LICENSING EVALUATOR NAME
:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
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
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & interview, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. Cleaning supplies were left accessible under the bathroom sink in a women's shared bathroom.
POC Due Date:
06/13/2024
Plan of Correction
1
2
3
4
Staff will secure cleaning solutions and make inaccessible to residents.
Type A
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, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Women's bathroom water temperature read at 123.4.
POC Due Date:
06/13/2024
Plan of Correction
1
2
3
4
Water heater needs to be adjusted to deliver water within limits. Verification will be sent to LPA.
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
3
of
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. Women's bathroom had hot water turned off when LPA initially attempted to test water.
POC Due Date:
06/13/2024
Plan of Correction
1
2
3
4
Hot water will remain on and plan will be sent to LPA.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. An exit door in R2's room is blocked by chair and other items.
POC Due Date:
06/13/2024
Plan of Correction
1
2
3
4
Staff will make arrangements to have obstructions removed from blocking exit door.
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
4
of
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met:
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 which poses an immediate health, safety or personal rights risk to persons in care. There are no documentation for R4's PRN medication
POC Due Date:
06/13/2024
Plan of Correction
1
2
3
4
Plan will be put into place to get resident's PRN documentation on file. Plan will be sent to LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
5
of
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.
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 which poses an immediate health, safety or personal rights risk to persons in care. R5 has no documentation indicating doctor's orders for PRN.
POC Due Date:
06/13/2024
Plan of Correction
1
2
3
4
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
6
of
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(3)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.
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 which poses an immediate health, safety or personal rights risk to persons in care. R5's inhaler is not stored in the original packaging with instructions.
POC Due Date:
06/13/2024
Plan of Correction
1
2
3
4
Plan to have training completed will be provided to LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
7
of
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed shared bathroom in women's area to not be maintained and has rust. Cabinet in bathroom has mold, window sill in wash room needs to be repaired, mold on windows, outlet cover broken in women's bathroom, & toilet paper dispenser is broken.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Verification of repairs will be sent to LPA.
Type B
Section Cited
CCR
85087(b)
Building and Grounds
(b) Stairways, inclines, ramps, open porches, and areas of potential hazard to clients whose balance or eyesight is poor shall not be used by clients unless such areas are well lighted and equipped with sturdy hand railings.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Hallway in leading to R3's room has no lighting.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Verification of lighting will be sent to LPA.
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
8
of
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
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, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed multiple residents to have broken blinds and torn screens.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Verification of window repairs will be sent to LPA
Type B
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Some resident's rooms have very low lighting which can make it difficult to see at night.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Verification of lighting correction will be sent to LPA.
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
9
of
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Bathroom in the male side of the facility had fecal matter on the bathroom floor.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Plan to keep floors free from fecal matter will be sent to LPA.
Type B
Section Cited
CCR
80088(f)(1)
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. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Trash cans in the bathrooms do not have tight fitted lids.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Trash cans will have tight fitted lids and verification will be sent to LPA.
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
10
of
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Couches in the outside area are torn and patched with duck tape.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Outdoor furniture will be replace or repaired properly. Verification will be sent to LPA
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Administrator does not have a current Administrator certificate on file at the facility.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Verification of current Administrator's Certification will be provided to LPA.
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
11
of
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Residents do not have current physician reports for the current facility.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Physician's reports need to be completed for current facility. Plan to correct needs to be provided to LPA.
Type B
Section Cited
CCR
80075(b)(1)(A)1
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must receive training from a licensed professional. 1. The licensee shall obtain written documentation from the licensed professional outlining the procedures and the names of facility staff who have been trained in those procedures.
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 which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs did not observe staff training to assist residents with inhalers.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Verification of staff trained to assist residents with inhalers needs to be provided to LPA.
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
12
of
14
Document Has Been Signed on
06/19/2024 12:09 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
06/12/2024
at
03:41 PM
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
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.
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 which poses/posed a potential health, safety or personal rights risk to persons in care. Facility did not have a completed disaster & mass casualty plan on file.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Facility needs to complete a disaster and mass casualty plan and provide verification to LPA.
Type B
Section Cited
CCR
80092.1(I)
(l) All training shall be documented in the facility personnel files.
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 which poses/posed a potential health, safety or personal rights risk to persons in care. Facility has no current training documented for staff. When LPA asked S1 for current training they stated it was in the file which had training last completed 2022.
POC Due Date:
06/26/2024
Plan of Correction
1
2
3
4
Verification of current training will not provided.
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:
Brenda Chan
LICENSING EVALUATOR NAME:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
13
of
14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME
FACILITY NUMBER:
275202407
VISIT DATE:
06/12/2024
NARRATIVE
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LPAs observed frozen meats removed from original packaging to have no date.
LPAs a sliding door in R3's bedrooms to not be in working condition.
LPAs observed for no doctor's orders for R4 PRN/OTC.
LPAs observed facility phone is only able to be used on speaker.
All citations were issued on LIC809D & civil Penalties issued.
Exit interview was conducted and a copy of this report LIC809, LIC 809D, and appeal rights were printed and provided to Staff Larry.
SUPERVISORS NAME
:
Brenda Chan
LICENSING EVALUATOR NAME
:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
LIC809
(FAS) - (06/04)
Page:
14
of
14