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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600663
Report Date: 04/24/2024
Date Signed: 04/24/2024 04:43:28 PM

Document Has Been Signed on 04/24/2024 04:43 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MONTEVERDE MANORFACILITY NUMBER:
415600663
ADMINISTRATOR/
DIRECTOR:		MARTIN, DINO MICHAELFACILITY TYPE:
740
ADDRESS:3420 FLEETWOOD DRIVETELEPHONE:
(650) 624-7624
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver, Maria Irma AlcantaraTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
NARRATIVE
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On April 24, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Irma Alcantara and explained the purpose of the visit. The administrator, Dino Martin arrived at the end of the inspection.

LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, garage, side yard and backyard. The facility has 5 resident rooms (one shared room) and 1 staff room. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. 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.

During the tour of the garage, LPA observed it was sectioned off in the middle and one side consisted of washer, dryer and storage cabinets and on the other side, a staff was sleeping in a tent and other furniture around it.

Hot water temperature in the kitchen and bathroom were measured at 106- 111 degrees Fahrenheit. Fire extinguisher checked and last inspected on October 26. 2023.
Sharps, chemical and toxins were observed to be locked and inaccessible to residents in care.
LPA reviewed 3 resident files and 3 staff files.

The following documents were requested submitted to CCL by 4/25/24:
- liability insurance; and copy of administrator certification.

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 civil penalties. .

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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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Document Has Been Signed on 04/24/2024 04:43 PM - It Cannot Be Edited


Created By: Murial Han On 04/24/2024 at 09:36 AM
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
FACILITY NUMBER: 415600663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2024
Section Cited

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87305 Alterations to Existing Building or New Facilities..(a) Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met as evidenced by:
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Based on observation and interview, LPA observed a staff was sleeping in the garage which poses an immediate health and safety risks to residents in care
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The administrator will develop a plan to ensure garage is not a living space for facility staff and submit a copy of the plan to CCL by 4/25/2024.
Type A
04/25/2024
Section Cited

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ยง1569.695 (c)Emergency Plans..c) A facility shall conduct a drill at least quarterly for each shift. This requirement is not met as evidenced by:
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Based on observation, interview and record review, the facility was not able to provide documents to proof that emergency drills were completed which poses an immediate 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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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