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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600754
Report Date: 05/06/2025
Date Signed: 05/06/2025 02:30:57 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/06/2025 02:30 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: 6DATE:
05/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver - KimIvanWilfred BudyTIME VISIT/
INSPECTION COMPLETED:
02:45 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 05/06/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with caregiver KimIvanWilfred Budy and explained the purpose of today's visit. Currently there are 6 residents present and 2 caregivers.

The facility is licensed for age range 60 years and over. All are approved to be non-ambulatory. Hospice waiver for 3 residents. Currently there are no residents on hospice per staff interviewed. The facility ambient temperature is comfortable. There are Required postings are in place observed in main dining area. Water temperature is tested in the common hallway full bathroom measuring as 135F near room 6. Additional bathroom water temperature is measured at 135F in another full bathroom near room 4. Cleaning supplies are observed to be locked in the garage primarily. Facility knives are observed to be locked in the kitchen in a drawer adjacent to the cooking range and stove. Facility food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. The garage has additional refrigerators with staff and resident food and additional emergency food supplies. Laundry area is observed in the garage as well and is fully operational. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. There is a locked storage shed in the backyard that contains garden supplies and furniture. Smoke detectors and carbon monoxide detectors are located through out the facility. LPA observed 3 fire extinguishers are observed in the facility. Both with inspection dates of 10/04/2024. Both are charged and ready for use. Facility conducts emergency drill quarterly. The last drill that was conducted is logged 04/30/2025. Linens are in place for resident in care.

Continued on next page...
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
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: 05/06/2025
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
Page 2

LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications are current, locked, and logged appropriately. First aid kit is present. There are two bathrooms, one is used as the main shower for residents, with grab bars and non-skid mats. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed 4 resident files and 4 staff files on this day. LPA observed that residents 1 through 4 do not have doctor orders for half bed rails or full bed rails. Staff training records are observed to be current and in place. Administrator certificate for Dino Martin is observed as current expiring 12/18/2024. LPA informed facility that annuals fees are overdue as of today's visit.

The following updated items are to be received by 05/13/2025:
• Copy of updated administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC402 Surety bond and Copy of active bond
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

Report is reviewed with KimIvanWilfred Budy. A copy of this report is provided to the facility.

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Technical advisory issued on attached LIC9102

Civil penalty is assessed due to a repeat violation which equals to $250. See attached LIC421FC(7/17)
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/06/2025 02:30 PM - It Cannot Be Edited


Created By: Jaime Vado On 05/06/2025 at 12:21 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: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2025
Section Cited
CCR
87303(e)(2)

1
2
3
4
5
6
7
(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 regulation has not been met as evidenced by:
1
2
3
4
5
6
7
Facility shall submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date of 05/07/2025.
8
9
10
11
12
13
14
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 135 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Civil penalty assessed on this day as this is a repeat violation within a 1 year period.

Civil penalty of $250 assessed
Type A
05/07/2025
Section Cited
CCR87608(a)(5)

1
2
3
4
5
6
7
POSTURAL SUPPORTS 87608(a)(5) - Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This regulation has not been met as evidenced by:
1
2
3
4
5
6
7
Facility shall submit photo proof of ALL full bed rails removed from resident beds to be removed or reduced to half size. Proof of correction to be submitting to licensing office by due date of 05/07/2025
8
9
10
11
12
13
14
Based on observations made, residents number R1, R2, and R4 have full bed rails. Licensee failed to prohibit use of full bed rails, which poses an immediate health, safety or personal rights risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/06/2025 02:30 PM - It Cannot Be Edited


Created By: Jaime Vado On 05/06/2025 at 12:54 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: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2025
Section Cited
CCR
87608(a)(3)

1
2
3
4
5
6
7
POSTURAL SUPPORTS 87608(a)(3) - A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.
This requirement has not met as evidenced by:
1
2
3
4
5
6
7
Facility shall submit written orders for all residents with half bed rails in place or remove them completely. Proof of correction to be submitting to licensing office on or before the due date of 05/13/2025.
8
9
10
11
12
13
14
Based on observations made, R3 is observed to have hafl bed rails in place but there is no order on file for the resident to have the bed rails in place. Those poses a potential health and safety risk.
8
9
10
11
12
13
14
Type B
05/13/2025
Section Cited
CCR87458(a)

1
2
3
4
5
6
7
87458(a) Medical Assessment - (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This regulation has not been met as evidenced by:
1
2
3
4
5
6
7
Facility shall ensure that ALL residents shall have either a current physicians report on file or assessments. Incoming residents shall have physicians reports on file at time of admission. Proof of correction to be submitting to licensing office on or before the due date of 05/13/2025.
8
9
10
11
12
13
14
Based on resident files reviewed, R3 does not have a physicians report on file.This poses a potential health and safety risk for residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 5