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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801611
Report Date: 12/10/2022
Date Signed: 12/11/2022 02:20:20 PM


Document Has Been Signed on 12/11/2022 02:20 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:MONTEREY LODGEFACILITY NUMBER:
405801611
ADMINISTRATOR:KATHLEEN TUCKERFACILITY TYPE:
740
ADDRESS:5255 MONTEREY ROADTELEPHONE:
(805) 226-7431
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:15CENSUS: 12DATE:
12/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Garrett Haner / Administrator TIME COMPLETED:
11:45 AM
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 At 9:00am on 12/10/2022, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct an annual; infection control inspection. Upon arrival, LPA was properly screen for COVID-19 and infection control and mitigation practices. LPA met with Administrator Garrett Haner and announced the reason for the visit.
At 9:45am, Administrator and LPA conducted a cursory tour of the facility. This facility is a 10 bedroom, 12 bathroom with kitchen, living room and dining room, There are ample outdoor areas in the front and in the back of the facility for resident to use with shade and seating. LPA observed at least 2 days of perishables and at least 7 days of non perishable foods. LPA noted that the water temperature in the facility was within regulation parameters. LPA noted that all necessary posting were posted in an easily accessible location. LPA noted that all areas of the facility were clean and free of hazards and obstructions. LPA noted that the bathrooms have liquid soap and paper towels in all the bathrooms. LPA noted that the facility has an ample supply of PPE for 3 facility's with capabilities for housing 15 residents at each facility. LPA noted that the medication cart was locked and secured in the hallway of the facility. LPA noted that on the cursory tour of the facility there were no visible violations and not citations were issued as a result of the cursory tour of the facility.
At 10:40am, Administrator and LPA conducted the infection control module of the annual inspection tool. LPA noted that there were no violations noted and no citations issues in the infection control module of this annual inspection.

Exit interview, Report singed, and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2022
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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