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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600663
Report Date: 05/24/2022
Date Signed: 05/24/2022 10:00:23 AM

Document Has Been Signed on 05/24/2022 10:00 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:
05/24/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Renato PeraTIME COMPLETED:
10:15 AM
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On May 24, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced plan of correction (POC) visit to follow up on POC visit made on May 12, 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. On 5/12/2022, LPA visited the facility to verify the POC, however, the facility administrator was unable to provide LPA Charitra with a POC. LPA issued a civil penalty from 5/4/2022 through 5/12/2022 and notified administrator that the civil penalty will continue to accrue until corrected.

On 5/18/2022, LPA Charitra received the POC from the Administrator. Deficiency is now verified as corrected and cleared.

Another civil penalty will be assessed in the amount of $100 a day from 5/12/2022 though 5/18/2022. Civil penalties stopped on 5/18/2022. Total civil penalty assessed today = $600.00

Report is reviewed with Caregiver and a copy is provided with appeal rights.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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