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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600754
Report Date: 10/15/2025
Date Signed: 10/15/2025 02:55:42 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2025 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20251006102504
FACILITY NAME:MONTEVERDE MANOR IIIFACILITY NUMBER:
415600754
ADMINISTRATOR:MARTIN, DINO MICHAEL A.FACILITY TYPE:
740
ADDRESS:2650 EDISON STREETTELEPHONE:
(650) 376-3053
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caregiver - KimIvanWilfred BudyTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff use the facility garage as a living unit
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/15/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit. LPA met with caregiver KimIvanWilfred Budy and explained the purpose of today's visit. According to the caregiver, all residents are present in the facility and there 3 staff present but 2 are on duty.

During today's visit, LPA toured the facility, observed the garage, and interviewed residents. LPA toured the facility and observed that there is a staff room on the way to the garage. LPA observed a bunk bed and staff belongings in this room. LPA observed the garage, which is accessible to this room via another door, and there are no indications of a bed or living furniture in the garage. The garage houses the laundry machine, dryer, refrigerator, and storage for facility supplies and other miscellaneous items. Based on the observations made, this allegations is unfounded.

This agency has investigated the complaint alleging, "Staff use the facility garage as a living unit". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Report is reviewed with KimIvanWilfred Budy and a copy is provided on this day.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2025 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20251006102504

FACILITY NAME:MONTEVERDE MANOR IIIFACILITY NUMBER:
415600754
ADMINISTRATOR:MARTIN, DINO MICHAEL A.FACILITY TYPE:
740
ADDRESS:2650 EDISON STREETTELEPHONE:
(650) 376-3053
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caregiver - KimIvanWilfred BudyTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff hit resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/15/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit. LPA met with caregiver KimIvanWilfred Budy and explained the purpose of today's visit. According to the caregiver, all residents are present in the facility and there 3 staff present but 2 are on duty.

During today's visit, LPA toured the facility, observed the garage, and interviewed residents. LPA interviewed 3 of 6 residents on this day regarding the allegation received. R1 through R3 do not have a dementia diagnosis and are interviewed. Per interviews conducted, none of the residents observed S1 hitting a resident in care. Residents interviewed did not indicate any mistreatment or visually seeing S1 hitting a resident in care. Based on these interviews and lack of information this allegation is unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with KimIvanWilfred Budy and a copy is provided on this day.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2