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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202407
Report Date: 09/24/2024
Date Signed: 09/24/2024 01:09:54 PM

Document Has Been Signed on 09/24/2024 01:09 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MONTEREY BAY GUEST HOMEFACILITY NUMBER:
275202407
ADMINISTRATOR/
DIRECTOR:
EMMANUEL & JENNIFER INNEHFACILITY TYPE:
735
ADDRESS:1100 CARSON STREETTELEPHONE:
(831) 920-1796
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY: 22CENSUS: 15DATE:
09/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:57 AM
MET WITH:Staff Larry RimasTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 9/24/2024 Licensing Program Analysts (LPAs) B. Miranda & R. Bruce arrived at the facility unannounced to check on the over due POC and the status of a resident who previously had an incident at the facility. LPAs introduced themselves and explained the reason for the visit. Staff Larry Rimas assisted with the visit.

LPA observed the following:
Facility has 2 carbon monoxide detectors which were no in working order
Handyman was on the way to fix the sliding screen door in room 3
Knives, tools, medication, & cleaning products to not be locked
Water temp in women's bathroom was not checked due to being occupied
Chair in resident's room was moved to allow access to exit door (cleared)
PRN medication is now be tracked and recorded (cleared)
Kitchen area has been cleaned, but there insects in the kitchen area
Windows/blinds have been replaced but there is some damage (cleared)
Glass window is broken and needs to be repaired
Broken furniture has been replaced (cleared)
Physician report is in a sample of resident files (cleared)
Log was not provided for emergency drills conducted

TV's generated will be emailed to the Licensee.

Exit interview was conducted and a copy of this report LIC809 was provided to staff Larry Rimas.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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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