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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604101
Report Date: 02/23/2024
Date Signed: 02/23/2024 04:17:02 PM

Document Has Been Signed on 02/23/2024 04:17 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MONTON RESIDENTIAL FACILITY INCFACILITY NUMBER:
374604101
ADMINISTRATOR:MONTON, LOIDAFACILITY TYPE:
735
ADDRESS:12323 JULIAN AVETELEPHONE:
(619) 749-4130
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: 5DATE:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Loida Monton, LicenseeTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Assistant Administrator/Caregiver Erlinda Samiano. LPA discussed the purpose of the visit with assistant administrator Samiano. Licensee Loida Monton later arrived and joined the visit.

According to the facility’s license, there may be a maximum of six (6) clients all of whom may be ambulatory, of which four (4) may be non-ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is five (5) clients living at the facility. There was 1 client present at the facility site during the inspection.

LPA, accompanied by Assistant Administrator Samiano and Licensee Monton, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities.

The facility’s ambient internal temperature was comfortable and compliant, at 72 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were almost all compliant: kitchen sinks hot water temperature measured at 118.9 degrees F; sink in restroom #1 delivered hot water at 118.9 degrees F; sink in restroom #2 delivered hot water at 125.1 degrees F and later measured at 108.1 degrees F; sink in restroom #3 delivered hot water at 119.8 degrees F; sink in restroom #4 delivered hot water at 120 degrees F; and sink in restroom #5 delivered hot water at 117.7 degrees F.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MONTON RESIDENTIAL FACILITY INC
FACILITY NUMBER: 374604101
VISIT DATE: 02/23/2024
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[CONTINUED FROM LIC 809]

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to clients. Medications were properly labeled, as required, and stored in a locked cabinet in the kitchen. The facility maintained medication logs which LPA reviewed.

No pools or bodies of water on the premises. Per licensee Monton, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present (01) and serviced within the last 12 months. First aid kit was complete and readily accessible.

LPA interviewed staff and client, and reviewed staff and client records. During today’s visit there was 1 client on the facility premise; 4 additional clients returned from their day program during the inspection. LPA was able to interview one client. LPA also interviewed a staff member. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There was a deficiency observed and cited during today's annual inspection and may be reviewed on the LIC809-D page of this report. The deficiency was cleared during the inspection.

An exit interview was conducted with Licensee Loida Monton to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Licensee Monton to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-D, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/23/2024 04:17 PM - It Cannot Be Edited


Created By: Carmen Lopez On 02/23/2024 at 03:12 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTON RESIDENTIAL FACILITY INC
FACILITY NUMBER: 374604101

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 1 out of 5 client bathrooms measured hot water temperature above 120 degrees farenheit which posed a potential safety risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Hot water temperature was adjusted during the inspection. LPA measured hot water temperature a second time and was cleared during the annual inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jennifer Lott
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024


LIC809 (FAS) - (06/04)
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