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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003883
Report Date: 11/16/2023
Date Signed: 11/16/2023 04:10:10 PM


Document Has Been Signed on 11/16/2023 04:10 PM - 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:DESCARGAR, BERNADETTEFACILITY TYPE:
740
ADDRESS:8700 SECKEL COURTTELEPHONE:
(916) 686-4836
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Bernadette DescargarTIME COMPLETED:
04:15 PM
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On 11/16/23, 2pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at the facility unannounced to conduct an annual inspection visit. LPA Villanueva met the administrator on paper, Bernadette Descargar and explained the purpose of the visit.

LPA evaluated the physical plant with the administrator to ensure the health and safety of the residents in care. Facility is a single-story home with a fire clearance to serve 6 non-ambulatory elderly residents and has hospice waiver for 6 residents. Facility has 6 resident bedrooms, one staff bedroom and 3 bathrooms for resident use. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature to be between 105-120 degree Fahrenheit in one of the bathrooms. Temperature inside the facility was observed to be 74 degrees F. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Carbon monoxide and smoke detectors are current and in compliance with fire safety. Fire extinguisher was last serviced on 1/24/23. First aid kit was checked and is complete. LPA observed centrally stored medications and toxins locked and secure from residents. LPA was sent annual required documents prior to annual inspection.

During this inspection 4 resident files and 5 staffing files were reviewed for regulatory compliance. Staff files contained the required contents including staff training requirements. All staff noted on LIC 500 have criminal background clearances and are associated to this facility.

{Con't on LIC809-C}

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MONTEREY, THE
FACILITY NUMBER: 347003883
VISIT DATE: 11/16/2023
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{Con't from LIC809}

Resident files reviewed contained required documents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance is current and update to date per regulatory requirements. LPA observed personal rights poster. Facility has appropriate internet access available for resident use.

Per California Code of Regulations, Title 22 and Health and Safety Codes, no deficiencies were observed during this visit. Interview was held with Bernadette Descargar and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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