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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003883
Report Date: 12/04/2024
Date Signed: 12/04/2024 11:06:12 AM

Document Has Been Signed on 12/04/2024 11:06 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MONTEREY, THEFACILITY NUMBER:
347003883
ADMINISTRATOR/
DIRECTOR:
DESCARGAR, BERNADETTEFACILITY TYPE:
740
ADDRESS:8700 SECKEL COURTTELEPHONE:
(916) 686-4836
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Bernadette DescargarTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 12/4/2024, Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced Case Management - Annual Continuation visit at the facility to continue with the Annual Required Inspection visit initiated on 11/21/2024. LPA initially met with a staff on duty (S1) and stated the purpose of the visit. The Administrator Bernadette Descargar was notified of this visit and arrived shortly after Present during today's visit were 6 residents in care with 2 staff on duty.

The LPA continued with facility visit to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Facility is fire cleared for 6 non-ambulatory residents and approved to admit/retain 6 hospice residents. LPA observed Oxygen Use sign at the entrance of the facility.

Review of 3 sample resident files (R1, R2, R3) include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Hospice residents was observed to have hospice care plan in place. No issues were noted at this time.

Medication review of 3 sample residents include review of physician orders for over-the-counter medications. No issues were noted at this time.

Review of 3 sample staff files (S1, S2, and S3) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator Certificate is current. No issues were noted at this time.

Facility conducts monthly disaster drill and last drill was on 11/20/24. Facility has a dementia and infection control plan.

Administrator provided a copy of current Liability Insurance Certificate, LIC500 and LIC308 to LPA.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during today's visit.

Exit interview was conducted and a copy of the report was provided upon exit.
Stephen RichardsonTELEPHONE: (916) 263-4700
Arvin VillanuevaTELEPHONE: 916-208-0023
DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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