<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600686
Report Date: 09/09/2024
Date Signed: 09/09/2024 03:22:06 PM

Document Has Been Signed on 09/09/2024 03:22 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DAMENIK'S HOMEFACILITY NUMBER:
415600686
ADMINISTRATOR/
DIRECTOR:		MONTILLA, DANILO F.FACILITY TYPE:
740
ADDRESS:767 MADDUX DRIVETELEPHONE:
(650) 756-5125
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 6DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Matthew Montilla, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On September 09, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Grace Donato, and Licensing Program Manager (LPM) April Cowan arrived at the facility at 12:50 PM to conduct the Annual 1-year required inspection. LPAs and LPM met with Matthew Montilla, Assistant Administrator, and explained the purpose of the visit.

LPAs and LPM toured the physical plant and found it to be clean at a comfortable indoor temperature with all exits free from obstruction. This is a single-story building with 5 resident bedrooms, 1 staff bedroom, 2½ bathrooms, a living room, and a kitchen with dining. No accessible bodies of water or hazards were observed. The fire extinguisher was fully charged and last serviced on October 2023. The carbon monoxide detector were observed not working. The attached garage was observed to be clean with a washer and dryer for laundry and extra food supply storage.

All rooms were observed to be clean with sufficient furniture and lighting. LPAs observed exit doors equipped with auditory alarms. The bathroom was observed to be mold-free and contained grab bars, liquid soap, and paper towels and a nonskid mat. At 1:10 PM, the hot water temperature in the bathroom sink faucet was measured at 123.8°F. At 2:15 PM, the water temperature was measured at 119.8°F.

Sharp objects, detergents, poisons, and soap were observed to be locked and inaccessible to persons in care. No expired food items were observed. The facility had the required 7 days of non-perishables and 2 days of perishables.

LPAs reviewed six resident records and three staff records. Emergency drills are conducted quarterly with the last drill documented on June, 2024.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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 3
Document Has Been Signed on 09/09/2024 03:22 PM - It Cannot Be Edited


Created By: Kiran Jain On 09/09/2024 at 02:42 PM
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: DAMENIK'S HOME
FACILITY NUMBER: 415600686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above due to carbon monoxide monitor not working during the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
1
2
3
4
The Administrator/Licensee is to submit proof that Carbon Monoxide monitor is in working condition. Licensee to submit by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DAMENIK'S HOME
FACILITY NUMBER: 415600686
VISIT DATE: 09/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The resident’s medications are securely stored in a locked cabinet. Medication administration records (MARs) were reviewed, and no expired medications were observed. The First Aid kit was checked and observed to be sufficiently stocked.

LPAs received updated Administrator Certificates for Danilo Montilla and Cynthia Montilla during the visit.

The following updated forms are requested to be submitted to CCLD:


· LIC 500: Personnel Report
· LIC 503: Health Screening Report
· Liability Insurance

A Type B Violation was provided for Carbon Monoxide detector not working in the facility.

The deficiency is cited under the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

An exit interview was conducted. This report was reviewed with Matthew Montilla, Assistant Administrator and a copy of this report along with appeal rights was left at the facility.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3