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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604441
Report Date: 01/13/2022
Date Signed: 01/13/2022 03:14:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MONTE VISTA VILLAGE SENIOR LIVINGFACILITY NUMBER:
374604441
ADMINISTRATOR:ZANCA-BROWN, SUSANFACILITY TYPE:
740
ADDRESS:2211 MASSACHUSETTS AVENUETELEPHONE:
(619) 465-1331
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:219CENSUS: 110DATE:
01/13/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maricor Laus, Resident Services Director
TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Tiffany Holmes, conducted an announced Pre-Licensing visit to observe the facility's compliance with Title 22, Division 6 regulations and the California health and safety code. LPA met with Maricor Laus, Resident Services Director.

During today's visit, LPA observed client rooms and found them to have proper furnishings, and adequate linens. Sinks accessible to clients had water temperatures measured at 115 degrees Fahrenheit. Facility had a working fire extinguisher. Smoke and carbon monoxide alarms were demonstrated to be operational by LPA Holmes. Facility had preparation space for food service and kitchen was observed to have all needed supplies for food service. Space inside the facility is sufficient for activities. Administrator stated that there are no weapons or ammunition on facility property. The body of water was observed on the facility property and was properly secured. Staff and client records will be stored in a locked cabinet in the business managers office. There is a shaded outdoor space and appropriate client activities. All cleaning supplies or potentially hazardous materials will be in a locked cabinet in the laundry area in the basement. Facility has a locked medication cart for client medications in each building and first aid kits in each building, front desk, kitchen and basement. Administrator certificate for Maricor Laus, Resident Services Director expired on 10/30/2021 and is waiting for renewal certificate. Component III was reviewed with Administrator. This report will be sent to Management for final review and approval.

An exit interview was conducted with Maricor Laus, Resident Services Director. A copy of this report and Applicant Rights (LIC 9058 01/16) will be provided via email. An electronic read receipt confirms receipt of these documents
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
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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