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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202407
Report Date: 07/14/2025
Date Signed: 07/14/2025 03:21:09 PM

Document Has Been Signed on 07/14/2025 03:21 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
FRESNO RO, 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: 19DATE:
07/14/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Emmanuel Inneh, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Daiquiri Boyd and Melinda Medina made an unannounced visit to the facility for the purpose of continuation of the Annual Inspection. LPAs were greeted by Caregiver, Larry Rimas, who granted entry. LPAs reviewed past inspection notes and requested the presence of Administrator.

Fire extinguisher was observed and had service from Tri-County Fire on 4/23/25. Water temperature was measured at 119.6 in the kitchen, and 101 in the bathrooms.
Resident files were observed on a previous visit. Staff files were observed on this day.
LPAs toured the facility inside and outside. Kitchen walls, cabinets, counter tops, stove, and refrigerator were all observed to be soiled with dirt and grease. Drawers containing knives and scissors had padlocks on them, but none of the locks were secured. Food observed met regulation. Chemicals in the kitchen were stored under the sink and unlocked. Other chemicals including resident's personal hygiene items were locked in a large storage closet in the living room area.
Resident rooms were missing chairs and lamps from 3 rooms observed. Closet door was broken from frame in bedroom #3. Holes were seen in the walls in various places throughout the facility. Light and outlet covers were missing or broken throughout the facility.
Bathrooms observed to have trash cans with no lids. Large tiles on the bathroom floor were loose in both bathrooms. General cleaning is needed in the bathrooms.
Laundry room window sill has chipped sheet rock and the wood frame underneath is now visible.
Outside courtyard area where residents gather, is littered with cigarette butts. Back patio observed to have items that should be discarded or secured as to not be a hazard to residents. Exit gate on north side of facility is difficult to open. (continued on next page)
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MONTEREY BAY GUEST HOME
FACILITY NUMBER: 275202407
VISIT DATE: 07/14/2025
NARRATIVE
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LPA asked for the following updated forms: LIC610D, Infection Control Plan, Client Roster(LIC9020), LIC500, to be e-FAXed to the Licensing Regional Office at (559)243-8088.

Licensee stated that he's receiving a grant from Monterey County to remodel this facility. Documents stating work to be done is to be sent to Licensing.

Deficiencies were cited on this day on the attached LIC809D.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/14/2025 03:21 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 07/14/2025 at 02:01 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: 07/14/2025

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
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Based on observation, the licensee did not comply with the section cited above in that chemicals and knives were observed unlocked on the back pation and in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
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4
Items were secured before the conclusion of this inspection.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in that the medication cart key is accessible and medciations were kept unlocked a the refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2025
Plan of Correction
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Licensee stated he will provide a refrigerator to store medications in the locked office.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 07/14/2025 03:21 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 07/14/2025 at 02:01 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: 07/14/2025

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 in kitchen the walls, counters, cabinets, refrigerator was not clean or sanitary which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2025
Plan of Correction
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Licensee to clean all surfaces in the kitchen area so there is no longer dirt and grease accumulation or staining.
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
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Based on observation, the licensee did not comply with the section cited above in all bathrooms water temperature measured at 101 degrees, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2025
Plan of Correction
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Licensee to increase water temperature to between 105 and 120 degrees and provide proof to LPA by photo.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 07/14/2025 03:21 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 07/14/2025 at 02:01 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: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
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. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in that resident bedrooms observed to be missing lamps and chairs for the residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2025
Plan of Correction
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Licensee to provide photos of purchase of lamps and chais in resident rooms.
Type B
Section Cited
CCR
85088(c)(3)
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. (3) Portable or permanent closets and drawer space in each bedroom to accommodate the client's clothing and personal belongings.

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 in that bedrooms observed to not have adequate furniture and supplies for personal belongings which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2025
Plan of Correction
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Licensee to provide adequate furniture for resident storage of personal belongings. Pictures to be submitted 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.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 07/14/2025 03:21 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 07/14/2025 at 02:01 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: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(C)
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: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2025
Plan of Correction
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Licensee to ensure that staff receive additional medication training to review proper documentation procedures. Agenda and sign in to to be submitted to LPA.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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