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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200308
Report Date: 07/01/2022
Date Signed: 07/01/2022 10:27:12 AM


Document Has Been Signed on 07/01/2022 10:27 AM - 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: 4DATE:
07/01/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elvie CardonaTIME COMPLETED:
10:30 AM
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
Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager (LPM) Jackie Jin, and Program Clinical Consultant (PCC) Nurse Lori Kopplinger conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Elvie Cardona..

Elvie Cardona reports that there are currently 2 COVID-19 positive residents and 0 COVID-19 positive staff.

During today's tele-visit, PCC Nurse Lori Kopplinger made the following recommendations to the facility:

1. Place Symptom Screening Area closer to door
2. Use visitor screening form for visitors
3. Place trash cans with foot pedal operated lids in the inside and outside of isolation rooms
4. Donning and Doffing posters should be placed near isolation rooms
5. Train staff how to Don and Doff PPEs
6. Have staff fit tested for N95 masks



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

This report was reviewed with with Lori Kopplinger. A copy of the report will be sent to them for it be signed and returned to CCL.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
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 1