<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600660
Report Date: 04/17/2024
Date Signed: 04/17/2024 09:29:01 PM

Document Has Been Signed on 04/17/2024 09:29 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MONTEVERDE MANOR IIFACILITY NUMBER:
415600660
ADMINISTRATOR/
DIRECTOR:		MARTIN, DINO MICHAEL A.FACILITY TYPE:
740
ADDRESS:2640 MUIRFIELD CIRCLETELEPHONE:
(650) 483-9997
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Caregiver, ILdefonso ManingTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On April 17, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, ILdefonso Maning and explained the purpose of the visit. The administrator, Dino Martin arrived shortly thereafter and assisted with the inspection.

Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.

Medication and sharps cabinets were locked located in the kitchen area and inaccessible to residents in care.

A tour of the resident bedrooms and restrooms was conducted. The facility is approved for 1 bedridden resident in room 4, however, LPA observed 1 bedridden resident is residing in a non-approved bedridden room. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.

Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees.

A comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. There are 6 residents present, and 3 staff but 1 staff left during the inspection due to lack of criminal background clearance.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 04/17/2024 09:29 PM - It Cannot Be Edited


Created By: Murial Han On 04/17/2024 at 11:37 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MONTEVERDE MANOR II
FACILITY NUMBER: 415600660

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above resident #1 (R1) is deemed to be bedridden and is residing in a room that is not approved for bedridden person which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
1
2
3
4
The administrator will developed a plan to ensure residents are residing in a room that is approved by the fire marshal based on their medical condition. In the plan, it shall include what action is the facility taken to ensure R1 is residing in an appropriate room. The administrator will provide a copy of the plan to CCL by 4/18/2024.
Type A
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed facility garage has been altered into living space for 2 staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
1
2
3
4
The administrator will remove all the livable supplies, items, toiletries, etc. in the garage and submit proof of completion to CCL by 4/18/2024. LPA administrator will develop a plan to ensure compliance and how to handle the living space situation for the facility staff and submit a copy of the plan to CCL by 4/18/2024
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/17/2024 09:29 PM - It Cannot Be Edited


Created By: Murial Han On 04/17/2024 at 11:37 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MONTEVERDE MANOR II
FACILITY NUMBER: 415600660

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed toxins and chemicals in the garage were unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure compliance and will provide copy of photos to CCL by 4/18/2024.
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 3 out of 4 staff files did not contained completed health screening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure compliance and on the plan, it shall indicate when these 3 staff will complete their health screening. The administrator will provide a copy of the plan to CCL by 4/18/2024.
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/17/2024 09:29 PM - It Cannot Be Edited


Created By: Murial Han On 04/17/2024 at 11:37 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MONTEVERDE MANOR II
FACILITY NUMBER: 415600660

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as one staff did not have criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure all staff are criminally background cleared prior to employment and will provide a copy of the plan to CCL by 4/18/2024.
Section Cited
Evaluation of Suitability for Admission
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/17/2024 09:29 PM - It Cannot Be Edited


Created By: Murial Han On 04/17/2024 at 11:37 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MONTEVERDE MANOR II
FACILITY NUMBER: 415600660

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility was not able to provide documents for the drills which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 4/18/2024
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/17/2024 09:29 PM - It Cannot Be Edited


Created By: Murial Han On 04/17/2024 at 11:37 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MONTEVERDE MANOR II
FACILITY NUMBER: 415600660

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 2 out of 4 staff were not associated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
1
2
3
4
The administrator will associate both staff and provide proof to CCL by 4/24/2024 that it has been completed.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 3 out of 4 residents files did not contained pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure compliance and a copy of each resident's completed pre-admission and/or appraisal service needs to CCL by 4/24/2024.
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MONTEVERDE MANOR II
FACILITY NUMBER: 415600660
VISIT DATE: 04/17/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A review of (5) facility resident records was conducted.
A review of (4) facility staff records was conducted.

Garage area was toured. LPA observed half of the garage was blocked off by green partition with two tents inside; each tent consisted of a mattress and around the tents, there were toiletries, clothing, shoes, etc. The administrator acknowledged that the facility altered this space as facility staff living space without permit.

The garage area also housed the washing machine and dryer for this facility's use at this time. Laundry area was toured. Cabinets storing detergents and bleach were observed to be unlocked and accessible to the residents at this time.

Fire extinguishers were inspected on 10/26/2023. Facility was not able to provide documentation to proof that emergency drills were completed accordingly.

The following forms and documents were requested to be updated and submitted into CCL by 4/22/24
- control of property, and liability insurance

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Civil penalty is being assessed today for repeat violation, lack of criminal background clearance for one staff, a bedridden resident is residing in a room that is not cleared by fire marshal and 2 out of 4 staff members were not associated. Civil penalty will continue to accrue until corrected.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7