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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801611
Report Date: 12/22/2023
Date Signed: 12/22/2023 02:24:21 PM


Document Has Been Signed on 12/22/2023 02:24 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: 10DATE:
12/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator - Garrett Haner-TomaskoTIME COMPLETED:
02:24 PM
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 At 10:00am Licensing Program Analyst (LPA) Jeffries arrived announced to the facility to conduct a annual facility inspection. LPA met with facility administrator Garrett Haner-Tomasko announced who he is and the reason for the visit. LPA was at 'sister' facility on same property conducting a pre licensing, change of ownership (CHOW) inspection on this day.
Administrator and LPA conducted a walking tour of the facility. LPA observed at least two days of perishable foods and at least 7 days of non perishable foods on hand for at least fifteen residents and staff. LPA noted that the facility was a comfortable 71 degrees (f). LPA tested the waster temperature to be within regulation range of 105*-120* (f). LPA noted that all bedrooms are properly furnished and have the appropriate lighting and linin. LPA noted that this facility has a locked med-cart located in the hallway of the facility. This facility is located on approximately 3 acres in a rural area. There is a gated complex with two identical facilities. This facility has 10 bedrooms and 12 bathrooms. Rooms are single and/or double occupancy which each of the 10 bedroom having a full privet bathroom, the other two bathrooms are resident, staff and visitor bathrooms that are in common areas. The facility has a sprinkler system and was pressure tested by Great Western Alarm on 12/14/2023. The carbon monoxides and smoke detectors are placed throughout the facility and are functioning properly. LPA observed 4 fire extinguisher placed throughout the facility all tested and in the green charge range. All passage ways and exits are free and clear of debris. LPA noted that the residents were engaged in daily activities and there is an activity calendar posted on the wall. LPA noted that all regulated posting were posted on the hallways in a conspicuous and accessible area.
Administrator and LPA conducted a full review of the annual care tools modules. LPA noted that no technical, violation, or citation were noted on the full review of the annual care tools modules review and no violations or citations were issued a result of the facility walk through inspection.

Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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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