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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 04:20:36 PM

Document Has Been Signed on 02/23/2024 04:20 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Loida Monton, LicenseeTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required annual inspection and in conjunction conducted this case management visit at the facility. LPA Lopez identified herself and was granted entry by Erlinda Samiano, Assistant Administrator/Caregiver. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Assistant Administrator Samiano and Licensee Loida Monton, who later arrived and joined the visit.

During today’s visit, LPA provided the Licensee Monton consultation and provided additional information regarding the Department’s website, Records to be Maintained at the Facility – Adult Residential (LIC 311C), Changes to Administrator Certification Training Requirements (PIN 23-14-CCLD), Criminal Background Clearance Transfer Request (LIC9182) and Criminal Record Exemption Transfer Request (LIC 9188) Form Updates (PIN 23-08-CCLD), Residential Care Facilities for the Elderly Reference Guide to Administrator, Staff, and Volunteer Training Requirements (PIN 23-16-ASC), and Revised Infection Control Regulations and Permanent Adoption (PIN 23-12-ASC).

No deficiencies were observed or cited during this case management visit. An exit interview was conducted with Licensee Monton and a copy of this report and Licensee/Appeal Rights (LIC 9058 3/22) were provided to the Licensee at the conclusion of the visit. The signature below confirms the documents were received.
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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