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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600754
Report Date: 05/24/2024
Date Signed: 05/24/2024 04:51:41 PM

Document Has Been Signed on 05/24/2024 04:51 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:MONTEVERDE MANOR IIIFACILITY NUMBER:
415600754
ADMINISTRATOR/
DIRECTOR:		MARTIN, DINO MICHAEL A.FACILITY TYPE:
740
ADDRESS:2650 EDISON STREETTELEPHONE:
(650) 376-3053
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 5DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Dave Enero and Benjie Guce, Caretakers and Dino Martin, Administrator/Licensee TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On May 24, 2024 at 2:00 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required visit. LPA Calandra was greeted by Benjie Guce and Dave Enaro, Caregivers and explained the purpose of his visit. Dino Martin, Licensee/Administrator arrived later during the visit.

LPA Calandra toured the physical plant. This is a 1-story building with 6 bedrooms and 2 bathrooms. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. All bedrooms were sufficiently lit and had the required furniture. All bathrooms had the required grab bars and anti-skid floor mats. The Fire extinguishers were observed to be fully charged and last checked on 10/9/2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. No hazards or obstructions were observed in the back and front yards, hallways, and other areas of the facility. The facility's fire and carbon monoxide detectors were observed to be in working condition. The first aid kit was observed to have all required supplies. The washer and dryer were observed to be in working condition.

All knives, sharp objects, soap, and detergents were observed to be locked and in-accessible to persons in care.

LPA Calandra reviewed 4 staff records and 5 client records. All were observed to be complete.

A Type A citation was provided for having faucets that delivered hot water measuring above 125 degrees Fahrenheit.

The Annual Inspection will be completed at a later date.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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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: MONTEVERDE MANOR III
FACILITY NUMBER: 415600754
VISIT DATE: 05/24/2024
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This report was reviewed with Dave Enero, Caregiver. A copy of the report along with appeal rights was left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2024 04:51 PM - It Cannot Be Edited


Created By: John Calandra On 05/24/2024 at 04:35 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: MONTEVERDE MANOR III
FACILITY NUMBER: 415600754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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87303(e)(2): Maintenance and Operations: Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bathroom faucets which delivered hot water at 134 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
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