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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424970
Report Date: 02/02/2024
Date Signed: 02/02/2024 11:03:55 AM


Document Has Been Signed on 02/02/2024 11:03 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MONTAGE MANORFACILITY NUMBER:
336424970
ADMINISTRATOR:CYNDY ZAECHFACILITY TYPE:
740
ADDRESS:69-920 MATISSE RDTELEPHONE:
(760) 699-5090
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 6DATE:
02/02/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:House Manager, Vanessa FrancoTIME COMPLETED:
11:20 AM
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On 02/02/2024, Licensing Program Analyst (LPA) Kathleen Banrasavong made an unannounced visit to the facility for confirmation of removal of an employee that has an exemption denial. LPA met with House Manager, Vanessa Franco and discussed the purpose of the visit.

The Criminal Record Exemption Denial notification letter dated 11/20/2023 was generated to notify the licensee that Nancy Villegas must not work or be present in the facility licensed by the Department. Franco stated that the facility has received the letter. LPA discussed the confirmation of removal notice with Franco. LPA was informed that Nancy Villegas has never worked at the facility or had an application submitted. Franco stated she understands the Exemption Denial letter and elements of it’s content. Franco states that Villegas was never associated with the facility therefore, there is no disassociation needed. Franco states that the facility has never received a potential application from the Nancy Villegas. There is no immediate concern for residents in care. There are no deficiencies being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6.

Based on evidence obtained during today's visit, the LPA has verified the individual is not present or employed at the facility. Verification of removal is complete. An exit interview was conducted where this report was discussed and provided to the House Manager, Vanessa Franco, as evidence by her signature.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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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