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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600663
Report Date: 08/10/2019
Date Signed: 08/10/2019 06:08:28 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:MONTEVERDE MANORFACILITY NUMBER:
415600663
ADMINISTRATOR:MARTIN, DINO MICHAELFACILITY TYPE:
740
ADDRESS:3420 FLEETWOOD DRIVETELEPHONE:
(650) 624-7624
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 6DATE:
08/10/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Staff Renato Pera and
Elarde Bautista 		TIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct the required - 1 year inspection. LPA met with staff Renato Pera and Elarde Bautista. LPA introduced self, informed the purpose of LPA's visit and requested to call Dino Michael Martin/Administrator. LPA spoke with Mr. Martin who indicated he can not come to the facility and authorized Mr. Pera to be with LPA during inspection and to sign and receive this report.

LPA toured the facility inside out with Mr. Pera. LPA inspected the living room, dining area, kitchen, bedrooms, bathrooms, garage, side yard and backyard. Food supplies were sufficient of perishables good for 2 days and non-perishables good for 7 days. Lamp and lights were present in all rooms and hallways. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Central storage for medications was locked.

Facility has working two-in-one carbon monoxide and smoke detectors. Hot water temperature in one of the bathrooms was tested and measured at 107.9 degrees Fahrenheit. Fire extinguisher checked, observed fully charge and tag showed serviced September 4, 2018.

At 12:51 pm, LPA observed resident's medication unlocked in the refrigerator,

LPA reviewed three (3) staff files. All three are fingerprint cleared and associated to this facility.

At 2:00 pm, LPA observed staff (S2) has only one (1) hour medication training on 2018.

........continued on 809C
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 725-7923
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2019
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: MONTEVERDE MANOR
FACILITY NUMBER: 415600663
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/11/2019
Section Cited

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87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, .......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 .... State Fire Marshal. (2) Bedridden persons
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This requirement is not met as evidenced by:

-Based on records review and interview, the licensee retained a bedridden resident and facility does not have fire clearance for bedridden. This poses immediate health and safety risks to resident in care.
Civil penalty assessed.
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Type A
08/11/2019
Section Cited

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87465 Incidental Medical and Dental Care: (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.
This requirement is not met as evidenced by:
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-Based on records review, the licensee failed to ensure R3 has current doctor's order for Lisinopril 5 mg. It's not clear whether or not the dosage has changed which poses immediate health and safety risks to resident in care.
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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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 725-7923
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: MONTEVERDE MANOR
FACILITY NUMBER: 415600663
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2019
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
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-Based on observation, the licensee failed to ensure medication is not readily accessible to residents in care. LPA observed medication unlocked in the refrigerator which poses immediate health and safety risks to residents in care.
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Type B
08/26/2019
Section Cited

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87463 Reappraisals: (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first.....
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This requirement is not met as evidenced by:

-Based on records review, the licensee failed to ensure residents' reappraisals are done at least annually. This poses potential health and safety risks to residents in care.
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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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 725-7923
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MONTEVERDE MANOR
FACILITY NUMBER: 415600663
VISIT DATE: 08/10/2019
NARRATIVE
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At 2:20 pm. LPA observed staff S3's file is incomplete; training records are not available for LPA to review. S3 started working on June 2019. LPA spoke with Mr. Martin over the phone who stated S3 has completed the training but has not printed the documents.

Six (6) resident records were reviewed. All six (6) have admission agreements on file.

At 2:50 pm. LPA observed residents' (R1, R4 and R5) Appraisal/Needs and Services Plans are more than a year old; on file were dated January 24, 2018.

At 3:05 pm, LPA reviewed resident's (R3) Physician's Report which revealed R3 is bedridden. LPA interviewed staff who confirmed R3 is not able to reposition on his own. LPA spoke with Mr. Martin over the phone and discussed this deficiency. R3 has order for the Lisinopril 10 mg dated April 13, 2019 but the medication on hand filled on July 29, 2019 showed 5 mg. . Facility does not have a copy of doctor's order of change of dosage.

The following documents/forms need to be updated and submitted to Community Care Licensing (CCL) by August 26, 2019:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan
4. Copy of proof of $3M liability insurance
5. Copy of Dino Michael Martin's current administrator certificate

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 809Ds. A $500.00 civil penalty is assessed for deficiency # 87202(a)(2). Failure to submit proof of corrections (POCs) by plan of correction due dates along with the LIC9098 Proof of Correction and any repeat violation within 12-month period may result in additional civil penalty.

Deficiencies and plan and proof of corrections were discussed with Mr. Martin over the phone and with Mr. Pera. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Mr. Pera.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 725-7923
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: MONTEVERDE MANOR
FACILITY NUMBER: 415600663
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2019
Section Cited

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87412 Personnel Records:
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. ...........

This requirement is not met as evidenced by:
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-Based on observation and interview, the licensee failed to ensure S3's record is made avaiiable for review. This poses potential health, safety and personal rights risk to residents in care.
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Type B
08/26/2019
Section Cited

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§1569.69 Employees assisting residents with self-administration of medication; training requirements (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.
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This requirement is not met as evidenced by:

-Based on records review, the licensee failed to ensure S2 has the required number of annual medication training. S2 has only one hour training on 2018 which poses potential health and safety risks to residents in care.
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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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 725-7923
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5