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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200308
Report Date: 12/07/2021
Date Signed: 12/07/2021 12:06:02 PM

Document Has Been Signed on 12/07/2021 12:06 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MONTE-FARLEY MANOR GUEST HOMEFACILITY NUMBER:
435200308
ADMINISTRATOR:CARDONA, ELVIRA B.FACILITY TYPE:
740
ADDRESS:579 FARLEY STREETTELEPHONE:
(650) 967-1758
CITY:MT. VIEWSTATE: CAZIP CODE:
94043
CAPACITY: 6CENSUS: 5DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Elvira CardonaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Elvira Cardona.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed a visitor screening area at the facility entrance. LPA Marrufo observed a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed PPE supplies for at least 30 days. LPA Marrufo observed 1 out of 1 resident bathroom and observed available soap and paper towels.

LPA Marrufo observed the facility hallways, outdoor areas, and outdoor storage areas.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator Elvira Cardona and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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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