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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600660
Report Date: 04/16/2026
Date Signed: 04/16/2026 03:39:08 PM

Document Has Been Signed on 04/16/2026 03:39 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 BRUNO RO, 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:
04/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Dino MartinTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On April 16, 2026 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregivers Remus Buensuceso and Maria Buensuceso and LPA explained the purpose of the visit. The administrator, Dino Martin arrived shortly thereafter and assisted with the inspection.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort.

Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable at this time.

Chemical, and sharps cabinets were observed to be locked and inaccessible to residents in care. However, Medication cabinets were unlocked and accessible to residents in care.

The facility is approved for 1 bedridden resident in room 4,and LPA observed resident #6 (R6) who was deemed to be bedridden on the LIC 602 was residing in room 2 that was not approved for bedridden resident.

Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.

Emergency drills were reviewed to be adequate.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2026
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 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 11
Document Has Been Signed on 04/16/2026 03:39 PM - It Cannot Be Edited


Created By: Murial Han On 04/16/2026 at 01:16 PM
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: 04/16/2026

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 as Based on documents reviewed, LPA observed R6 is bedridden, however, R6 was residing in a room that was not approved for bedridden resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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2
3
4
The administrator will submit a plan of correction to ensure compliance by 4/17/2026.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the hot water temperature in the kitchen and the resident bathroom/shower room was measured above 150 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
1
2
3
4
The administrator will submit a plan of correction to ensure compliance by 4/17/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 04/16/2026 03:39 PM - It Cannot Be Edited


Created By: Murial Han On 04/16/2026 at 01:16 PM
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: 04/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as based on records review, LPA observed S2 did not have a health screen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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2
3
4
The administrator will provide a plan of correction to CCL by 4/17/2026.
Type A
Section Cited
CCR
87412(a)(13)(B)
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: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S1 and S2 did not have criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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2
3
4
The administrator will provide a plan of correction to CCL by 4/17/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 04/16/2026 03:39 PM - It Cannot Be Edited


Created By: Murial Han On 04/16/2026 at 01:16 PM
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: 04/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87613(a)(2)(B)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S2 did not have any training prior to providing care to the residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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The administrator will provide a plan of correction by 4/17/2026 to ensure compliance.
Type A
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as upon entering the facility until the completion of the inspection, LPA did not observe any activities for the residents. LPA observed 4 residents were in bed, and 2 residents were on the couch in the living room (one was watching TV and the other one was sleeping). which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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2
3
4
The administrator will provide a plan of correction to CCL by 4/17/2026 indicating the actions that the facility will take to ensure facility has variety of planned activities to offer and to encourage residents to attend.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 04/16/2026 03:39 PM - It Cannot Be Edited


Created By: Murial Han On 04/16/2026 at 01:16 PM
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: 04/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 During the tour of the facility, LPA observed medications 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: 04/17/2026
Plan of Correction
1
2
3
4
The administrator will submit a plan of correction to CCL by 4/17/2026 indicating the action(s) that the facility will take to ensure centrally stroed medication is locked and inaccessible to residents at all times.
Section Cited
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 04/16/2026 03:39 PM - It Cannot Be Edited


Created By: Murial Han On 04/16/2026 at 01:16 PM
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: 04/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

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 based on records review, LPA observed R3 did not have a pre-placement appraisal which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
1
2
3
4
The administrator will provide a plan of correction to CCL by 4/17/2026 to ensure compliance and will provide a copy of the pre-admission appraisal to CCL by 4/27/2026.
Type A
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 based on records review, LPA observed R1 and R4 did not have an updated reappraisal which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
1
2
3
4
The administrator will provide a plan of correction to CCL by 4/17/2026 to ensure compliance and will provide a copy of the reappraisal for R1 and R4 to CCL by 4/27/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 04/16/2026 03:39 PM - It Cannot Be Edited


Created By: Murial Han On 04/16/2026 at 01:16 PM
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: 04/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 based on observation and record review, LPA observed R3 and R5 have half bedrails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
1
2
3
4
The administrator will develop a plan of correction to ensure compliance and will provide a copy of the plan to CCL by 4/17/2026. The administrator will ensure a physician's order is obtained for R3 and R5's bed rails by 4/27/2026.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 04/16/2026 03:39 PM - It Cannot Be Edited


Created By: Murial Han On 04/16/2026 at 01:16 PM
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: 04/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 based on records reveiw and interview, LPA observed S1 did not have annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
1
2
3
4
The administrator will provide a plan of correction to ensure compliance by 4/27/2026.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 04/16/2026 03:39 PM - It Cannot Be Edited


Created By: Murial Han On 04/16/2026 at 01:20 PM
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: 04/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)(3)
87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
(3) Ability to maintain or supervise the maintenance of financial and other records.

This requirement is not met as evidenced by: Based on observation, interview and record review, the facility has multiple repeat violations from the annual inspections from 2024, 2025 and 2026.
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as based on observation, interview and record review, the facility has multiple repeat violations from the annual inspections from 2024, 2025 and 2026 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
1
2
3
4
The administrator stated that he will be more hands-on with the facility's operation/care and supervision. The administrator will provide a plan of correction indicating the details of the "hands-on" involvement at the facility. The administrator will provide a copy of the plan of correction to CCL by 4/17/2026.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MONTEVERDE MANOR II
FACILITY NUMBER: 415600660
VISIT DATE: 04/16/2026
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A review of (6) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

During the review of staff files, LPA observed staff #1 (S1 ) and Staff #2 (S2) did not have a criminal background clearance. LPA spoke with the administrator who brought additional staff members to the facility and S1 and S2 were removed.

Civil penalty is being assessed today for the following citations in the amount of $1500
- 87202(a)(2) Bedridden Persons- $500
- 87412(a)(13)(B) Criminal Background Clearance- $1000

The following forms and documents were requested to submitted to CCL by 4/27/2026:
- liability insurance, Administrator Certification, LIC 500 and Lease Agreement

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 addition civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC809 (FAS) - (06/04)
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