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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600663
Report Date: 04/26/2022
Date Signed: 04/26/2022 10:06:41 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220420100804
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:
04/26/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Dino MartinTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Facility failed to provide authorized representative with resident’s medical records
INVESTIGATION FINDINGS:
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On April 26, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced 10-day complaint visit regarding the above allegation. LPA met with Administrator, Dino Martin and explained the purpose of the visit.

Regarding the allegation that the facility failed to provide authorized representative with resident's medical records, according to complainant, the resident (R1) passed away back in June of 2021 and the responsible party has been trying to obtain R1's medical records serval times but the facility failed to provide them. According to the Administrator, it was indicated that due to the pandemic and personal issues, he has not yet had a chance to provide the responsible party with R1's documents.

Based on the information collected and interviews conducted, it was determined that the facility failed to provide authorized representative with resident's medical records. The preponderance of evidence standard has been met, therefore the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Dino Martin, a copy is provided with appeals rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20220420100804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MONTEVERDE MANOR
FACILITY NUMBER: 415600663
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2022
Section Cited
CCR
87506(c)(1)
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87506 Resident Records: (c) All information and records obtained from or regarding residents shall be confidential.(1) The licensee shall be responsible for storing active and inactive records... The licensee... shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.

Violation of this regulation is not met as evidence by:
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Administrator will provide resident's responsible party with a copy of resident's file. In addition, Administrator will submit a copy of email, fax cover sheet, or copy of receipt to CCLD as proof or correction.
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Based on information collection and interviews conducted, it was indicated that the due to the pandemic and personal issues, the administrator has not had a chance to provide the responsible party with Resident's (R1's) documents.
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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: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2