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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200308
Report Date: 12/01/2022
Date Signed: 12/01/2022 01:45:01 PM


Document Has Been Signed on 12/01/2022 01:45 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
CENTRAL COAST CR/RES, 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:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Care Staff, Adelaida GiwagiwTIME COMPLETED:
02:00 PM
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On 12/1/2022 at 1:05pm, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with care staff Rosario Cadilena, Adelaida Giwagiw and Rustica Tugade. Administrator (ADM) Elvira Cardona was unable to meet LPA Rai for the visit. LPA Rai spoke to ADM over the phone and received verbal confirmation to conduct the visit with care staff Adelaida Giwagiw.

During visit, LPA Rai toured the facility inside. Due to the rain storm, LPA Rai observed the outside through various windows and patio doors. LPA Rai observed a visitor screening area at the facility entrance. LPA Rai observed a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Rai observed PPE supplies. LPA Rai observed 4 out of 4 resident bathroom and observed available soap and paper towels.

LPA Rai observed the facility hallways, garage, kitchen and living room.

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

This report was reviewed with care staff Adelaida Giwagiw and a copy of this report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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