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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 01:02:47 PM

Document Has Been Signed on 09/24/2024 01:02 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:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:52 AM
MET WITH:Staff Larry RimasTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 9/24/2024 Licensing Program Analysts (LPAs) B. Miranda & R. Bruce arrived at the facility unannounced to check on R1's status at the facility, who previously had an incident at the facility. LPAs introduced themselves and explained the reason for the visit. LPAs met with Staff Larry Rimas.

On 8/22/24 LPA received an email from Licensee Emmanuel Inneh stating R1 had made threats to a Monterey County employee, facility staff, and other residents. Incident reports are supposed to be sent to the regional office. The email contained the incident report and a letter from Monterey County acknowledging the threat that was made. Licensee stated 30-day eviction notice was faxed to the office. LPA was not able to locate verification.

When LPAs arrived to the facility the staff was able to provide the documentation but not verification the 30-day eviction notice was sent to the Dept. Citation was issued.

Exit interview was conducted and a copy of this report LIC809, LIC809D, & appeal rights were 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)
Page: 1 of 2
Document Has Been Signed on 09/24/2024 01:02 PM - It Cannot Be Edited


Created By: Brianna Miranda On 09/24/2024 at 11:59 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MONTEREY BAY GUEST HOME
FACILITY NUMBER: 275202407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2024
Section Cited
CCR
85068.5(2)(e)

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85068.5 Eviction Procedures
(2) The client has engaged or is engaging in behavior which is a threat to his/her mental and/or physical health or safety, or to the health and safety of others in the facility. (e) A written report of any eviction processed in accordance with (a) above shall be sent to the licensing agency within five days of the eviction.

This requirement is not met as evidenced by:
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Policyy will be out into place. Verification will be sent to LPA by due date.
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Based on observation, interview, record review the licensee The licensee did not provide a copy of the 30- day eviction notice that was issued to R1.
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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: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
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