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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294335
Report Date: 12/15/2021
Date Signed: 12/17/2021 10:08:18 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:AVE MARIA RCFE #1FACILITY NUMBER:
275294335
ADMINISTRATOR:BARBARA REIDFACILITY TYPE:
740
ADDRESS:1249 JOSSELYN CANYON ROADTELEPHONE:
(831) 373-1216
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:49CENSUS: 8DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kristine WareTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Kristine Ware Assisted Living Director and Susan Mayer Administrator.

LPA toured the facility buildings(2) inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in a locked medication cart in the dining area. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening with questionnaire. Signs posted included Mask Required, Proof of COVID Test or Vaccination Required, Wash Your Hands, Stop the Spread, Cough Etiquette and Donning and Doffing instructions. Bathrooms observed to be supplied with hygiene products. Hand washing signs posted. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE) and Emergency PPE cart ready for use. Additional staff training on PPE donning and doffing conducted on 9/28/2021.

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, and N95 Fit Testing.

No citations issued per the California Code of Regulations Tittle 22.

LPA reviewed report with Kristine Ware Assisted Living Director and Susan Mayer Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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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