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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
275202549
Report Date:
08/28/2024
Date Signed:
09/06/2024 07:45:25 AM
Document Has Been Signed on
09/06/2024 07:45 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
FRESNO ASC
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
MONTEREY BAY GUEST HOME #2
FACILITY NUMBER:
275202549
ADMINISTRATOR/
DIRECTOR:
INNEH, EMMANUEL
FACILITY TYPE:
735
ADDRESS:
645 WILLIAMS ROAD
TELEPHONE:
(831) 975-4970
CITY:
SALINAS
STATE:
CA
ZIP CODE:
93905
CAPACITY:
40
CENSUS:
36
DATE:
08/28/2024
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:
Licensee, Emmanuel Inneh
TIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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Licensing Program Analyst (LPA)'s S. Hurt and S.Doucette arrived at the facility unannounced to conduct an Required Annual Inspection. LPA's were granted entry by Licensee Emmanuel Inneh. LPA's explained the purpose of todays visit.
LPA's reviewed records for 3 facility clients, and 3 facility staff.
LPA's confirmed all staff present is background cleared. Resident 1 does not have complete Admission agreement in file. Staff 1 does not have required Health Screening Report (LIC 503) in file. LPA's observed water temperature in facility resident bathroom located in hallway measured at 100 degrees. The Licensee could not provide current/updated resident roster. LPA's observed facility Resident 2's PRN medications were not correctly documented.
Exit interview conducted with Emmanuel Inneh, and a copy of this report provided, along with appeals rights provided.
SUPERVISORS NAME
:
Brenda Chan
LICENSING EVALUATOR NAME
:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
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
8
Document Has Been Signed on
09/06/2024 07:45 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
08/28/2024
at
04:19 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
,
,
CA
FACILITY NAME:
MONTEREY BAY GUEST HOME #2
FACILITY NUMBER:
275202549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.
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 in LPA's observed roaches in food pantry area, and food preparation area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to send proof facility kitchen area is free of roaches, and send proof to LPA's by POC date of 09/11/2024.
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:
Stephenie Doub
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
09/06/2024 07:45 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
08/28/2024
at
04:19 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
,
,
CA
FACILITY NAME:
MONTEREY BAY GUEST HOME #2
FACILITY NUMBER:
275202549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/28/2024
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 in LPA's observed the facility nightstands to be very dusty, floors are dirty, walls are dirty, doors are dirty, cobwebs in corners, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to deep clean facility, and send proof to LPA by POC date of 09/11/2024.
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.
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 in LPA's observed cockroaches in facility kitchen area, pantry food storage area, facility bathrooms, and boxes located in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to ensure the facility is free of insects, including spiders, and roaches, and send proof to LPA's by POC date of 09/11/2024.
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:
Stephenie Doub
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
09/06/2024 07:45 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
08/28/2024
at
04:19 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
,
,
CA
FACILITY NAME:
MONTEREY BAY GUEST HOME #2
FACILITY NUMBER:
275202549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(a)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).
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 in the facilities hallway thermometer is in disrepair, and does not show facilities temperature, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to ensure the facilties thermostat is operating properly, and send proof to LPA by POC date of 09/11/2024.
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 obeservation, the licensee did not comply with the section cited above in LPA's observed several client bedroom window screenswith rips, tears, and bent, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to repair broken window screens, and send proof to LPA's by POC date of 09/11/2024.
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:
Stephenie Doub
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
09/06/2024 07:45 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
08/28/2024
at
04:19 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
,
,
CA
FACILITY NAME:
MONTEREY BAY GUEST HOME #2
FACILITY NUMBER:
275202549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(g)
Fixtures, Furniture, Equipment, and Supplies
(g) The licensee shall provide linens of various kinds necessary to meet the program of services being offered by the facility and the requirements specified in Chapters 2 through 7.
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 in LPA's observed several facility clients with no linen/ bedding on mattress, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide proof of sufficient linen supply, and submit to LPA by POC date of 09/11/2024,
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LPA's observed facility clients do not have drawers separate from night stand, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee will provide proof of drawer space for each client, and submit proof to LPA's by POC date of 09/11/2024.
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:
Stephenie Doub
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
09/06/2024 07:45 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
08/28/2024
at
04:19 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
,
,
CA
FACILITY NAME:
MONTEREY BAY GUEST HOME #2
FACILITY NUMBER:
275202549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)
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. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.
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 in LPA's observed several facility mattresses with dirty linens, several mattresses do not have linenes, mattresses not correct size for frame, and springs in several mattresses and box springs are not in good repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to audit facility mattresses, and box springs to ensure all are in good repair, with required linens, and send proof to LPA's by POC date of 09/11/2024.
Type B
Section Cited
CCR
85064(e)
Administrator Qualifications and Duties
(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.
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 in the facility is out of compliance with Title 22 regulations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee will agree to bring the facility into compliance with 22 Regulations by POC date of 09/11/2024.
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:
Stephenie Doub
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
09/06/2024 07:45 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
08/28/2024
at
04:19 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
,
,
CA
FACILITY NAME:
MONTEREY BAY GUEST HOME #2
FACILITY NUMBER:
275202549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Staff 1 does not have required Health Screening Report (LIC 503), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide required Health Screening Report (LIC 503) to LPA's by POC date 09/11/2024.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
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 in LPA's observed facility pantry does not have required perishable food supply, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide proof of required 7 day perishable food supply, and submit to LPA's by POC date of 09/11/2024.
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:
Stephenie Doub
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
09/06/2024 07:45 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
08/28/2024
at
04:19 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
,
,
CA
FACILITY NAME:
MONTEREY BAY GUEST HOME #2
FACILITY NUMBER:
275202549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Resident 1 does not have complete Admission Agreement in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit copies of completed Admission Agreement for Resident 1 to LPA by POC date of 09/12/2024.
Type B
Section Cited
HSC
1565(e)(1)
Other Provisions
(e) A facility shall have all of the following information readily available during an emergency: (1) A roster of individuals served by the facility, with the date of birth for each individual.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in, the facility does not have a roster of all residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide complete roster of residents with date of births to LPA's by POC date of 09/11/2024.
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:
Stephenie Doub
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2024
LIC809
(FAS) - (06/04)
Page:
8
of
8