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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600663
Report Date: 05/12/2022
Date Signed: 05/12/2022 09:21:15 AM

Document Has Been Signed on 05/12/2022 09:21 AM - 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
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: 5DATE:
05/12/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver, Renato PeraTIME COMPLETED:
09:30 AM
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On May 12, 2022, Licensing Program Analysts (LPA) Komal Charitra conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citation that were issued on 4/26/2022. LPA Charitra met with Caregiver, Renato Pera, and explained the purpose of the visit. Caregiver called, Administrator, Dino Martin and LPA also explained the purpose of the visit.

On 4/26/2022, the facility was cited for California Code of Regulation (CCR), 87506(c)(1) Resident Records. The plan of correction for this citation was due to CCLD by 5/3/2022, however the facility administrator failed to provide CCLD a plan of correction by the due date. In addition, facility administrator did not ask LPA Charitra for an extension.

During the visit, administrator was still not able to provide LPA with a POC for the cited deficiency. However, the administrator did indicate he is currently working clearing the deficiency.

Due to the citation 87506(c)(1) Resident Records, not being corrected by 5/3/2022, a civil penalty is being assessed in the amount of $100 a day from 5/4/2022 through 5/12/2022 and will continue to accrue until corrected.

Report is reviewed with Caregiver, Renato Pera, and a copy if provided with the appeal rights.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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