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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
275202549
Report Date:
10/20/2023
Date Signed:
10/23/2023 11:41:04 AM
Document Has Been Signed on
10/23/2023 11:41 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:
INNEH, EMMANUEL
FACILITY TYPE:
735
ADDRESS:
645 WILLIAMS ROAD
TELEPHONE:
(831) 975-4970
CITY:
SALINAS
STATE:
CA
ZIP CODE:
93905
CAPACITY:
40
CENSUS:
33
DATE:
10/20/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:30 AM
MET WITH:
Administrator, Emmanuel Inneh
TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator, Emmanuel Inneh, Continual Administrator's Certification for Jennifer Inneh expires May 18, 2024. There are currently 33 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.
Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector. Water temperature was tested at 121 degrees. LPA Hurt observed toxins and cleaning supplies in resident bathroom accessible to residents. LPA observed resident dressers broken, bedside lamps broken, bathroom vanities broken. LPA observed several small gnat like bugs in resident bathrooms. LPA Hurt observed several resident bedrooms without a mattress or with a warped mattress. LPA observed several resident mattresses with no sheets. LPA observed a large container with beans in the facility kitchen with a dead bug inside the beans. LPA observed facility resident bathrooms to be extremely dirty. LPA observed facility resident bathrooms with no paper towels or hand towels to dry hands. LPA observed fencing in the back patio area to be wobbly and broken, and a separate wood structure with old wet wood boards on it. LPA observed several resident closet doors to be broken. Facility staff could not provide proof of required disaster drills. The facility does not have a current activities calendar. LPA observed several window screens to be ripped and torn.
LPA Hurt will return on a later date to complete inspection.
The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.
LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610 the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file.
Listed documents shall be sent to Licensing.
Exit interview conducted with facility staff Emmanuel Inneh, and copy of report left at facility
SUPERVISORS NAME
:
Brenda Chan
LICENSING EVALUATOR NAME
:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/20/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/20/2023
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
9
Document Has Been Signed on
10/23/2023 11:41 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
10/20/2023
at
02:31 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:
10/20/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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3
4
Based on observation, the licensee did not comply with the section cited above in LPA observed facility restrooms to be very dirty, with what appears to be dirt and mold around bottom of the toilets which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/03/2023
Plan of Correction
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4
Facility staff will deep clean resident bathrooms and send proof to LPA by POC date of 11/03/2023.
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
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Based on observation , the licensee did not comply with the section cited above in LPA observed facility resident bathroom trash does not have a lid, and is an old laundry bucket re purposed as a trash bin which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/03/2023
Plan of Correction
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3
4
Administrator will ensure resident bathrooms have trash bins with lids, and submit proof to LPA by POC date of 11/03/2023
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:
10/20/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/20/2023
LIC809
(FAS) - (06/04)
Page:
2
of
9
Document Has Been Signed on
10/23/2023 11:41 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
10/20/2023
at
02:32 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:
10/20/2023
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 LPA observed several resident nightstands, and bedside lamps to be broken, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/03/2023
Plan of Correction
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4
Administrator will replace or fix broken furiture, and lamps and send proof to LPA by POC date of 11/03/2023.
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 observed several resident mattresses with no sheets, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/03/2023
Plan of Correction
1
2
3
4
Administrator will ensure all resident mattresses have clean sheets, and provide proof to LPA by POC date of 11/03/2023.
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:
10/20/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/20/2023
LIC809
(FAS) - (06/04)
Page:
3
of
9
Document Has Been Signed on
10/23/2023 11:41 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
10/20/2023
at
02:33 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:
10/20/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in Administrator could not provide proof of
required documented drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/03/2023
Plan of Correction
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3
4
Administrator will conduct required fire, earthquake drills and send proof to LPA by POC date of 11/03/2023
Type B
Section Cited
CCR
85079(a)
Activities
(a) The licensee shall ensure that planned recreational activities, which include the following, are provided for the clients:
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 Administrator did not provide a current
activities calendar which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/03/2023
Plan of Correction
1
2
3
4
Administrator will send current updated activities calendar and send proof to LPA by POC date of 11/03/2023.
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:
10/20/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/20/2023
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
10/23/2023 11:41 AM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
10/23/2023
at
11:34 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 #2
FACILITY NUMBER:
275202549
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/20/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(1)
(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. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).
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 observed several residents with mattresses not in good repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/03/2023
Plan of Correction
1
2
3
4
Administrator will replace resident mattresses that are not in good repair and send proof to LPA by POC date of 11/03/2023
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:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
10/23/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/23/2023
LIC809
(FAS) - (06/04)
Page:
9
of
9