415600754-8-1-2022-14-AS-KCHA-CGVRXK-20220801132452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600754
Report Date: 08/01/2022
Date Signed: 08/01/2022 01:25:02 PM

Document Has Been Signed on 08/01/2022 01:25 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 MANOR III		FACILITY NUMBER:	415600754
ADMINISTRATOR:	MARTIN, DINO MICHAEL A.		FACILITY TYPE:	740
ADDRESS:	2650 EDISON STREET		TELEPHONE:	(650) 376-3053
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 6	DATE:	08/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator, Dino Martino		TIME COMPLETED:	01:35 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 August 1, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted on the front door. LPA met with Administrator, Dino Martin and explained the purpose of the visit. Administrator was able to provide LPA screening log documentation for visitors, staff and residents. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 6 resident bedrooms, 1 staff room, and 3 full bathrooms. LPA observed all resident bedrooms to be private rooms. Bathrooms were observed to be equipped with liquid soap, paper towels, and a hand washing sign. LPA advised administrator to ensure trash cans are covered with a lid. Infection control practices are present: entry procedures, daily monitoring for residents and staff, COVID-19 signage posted throughout the facility, and 30-day PPE supply. LPA toured the living room and dining room and it was clear and free from any tripping hazards. A comfortable temperature was maintained, lighting is sufficient for comfort. LPA toured the kitchen, medications, toxins and sharps are stored appropriately and inaccessible to residents. LPA observed 2 day perishable and 7 day non-perishable present. First aid kit was observed to be completed. Extra linen was observed to be present. LPA observed the staff room which lead to the garage. The garage was observed to have extra food supply. Washer and dryer was observed to be in good working condition. LPA observed an attic above the garage with clothes and boxes. According to the Administrator, no staff are sleeping in the attic, however is looking into obtaining fire clearance for the attic to be used as a staff room. (CONT. to 809C)

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 MANOR III	FACILITY NUMBER: 415600754
	VISIT DATE: 08/01/2022

NARRATIVE

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It was found during the visit that a staff member (S1) was not associated to the facility. LPA reviewed the staff roster with the Administrator and confirmed that S1 is not associated to the facility but does have a fingerprint clearance.

This violation results in an immediate civil penalty of $100.00.

LPA requests the following forms to be submitted to CCLD by 8/8/22:

LIC308 Designation of Administrative Responsibility
LIC500 Personnel Report
LIC610E Emergency Disaster Plan
Administrator Certificate

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

This report was reviewed and discussed with Administrator, and a copy is provided with appeal rights.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/01/2022 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 MANOR III	FACILITY NUMBER: 415600754
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, it was indicated that S1 is not associated to the facility. Although Administrator was able to provide LPA with fingerprint clearance documentation and proof of association submission to CCLD, S1 did not get associated due to insufficient documents.
	POC Due Date: 08/02/2022
	Plan of Correction
1 2 3 4	During the visit, Administrator provided LPA documentation regarding S1 fingerprint clearance and criminal record transfer.

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

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