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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200308
Report Date: 04/12/2024
Date Signed: 04/12/2024 11:37:49 AM


Document Has Been Signed on 04/12/2024 11:37 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
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:
04/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elvira CardonaTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident visit and met with Administrator Elvira Cardona.

The purpose of the visit was to follow up with an Incident Report submitted by the facility on 02/06/2024 regarding an incident that occurred on 02/05/2024. The Incident Report stated that a hospice nurse observed a resident had a multiple bruises on his/her left hip. The Incident Report states the hospice nurse showered the resident at the facility that morning.

During visit, LPA Marrufo measured the water temperatures at the facility. LPA Marrufo measured water temperature in the hallway bathroom that Administrator Cardona stated the staff used to shower the resident. In the hallway bathroom, the sink water was measured at 164 F and the water coming from the shower head measured at 156 F.

The water temperature in the sink of one resident bedroom bathroom measured at 169 F and in the sink of a second resident bedroom bathroom measured at 168 F.

LPA Marrufo toured the facility garage and observed the water boiler had the heat setting set to "Very Hot."

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Administrator Cardona and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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Document Has Been Signed on 04/12/2024 11:37 AM - 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: MONTE-FARLEY MANOR GUEST HOME
FACILITY NUMBER: 435200308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2024
Section Cited
CCR
87303(e)(2)

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87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the
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Licensee agrees to submit a Plan of Correction by POC date stating how the facility will ensure that faucets used by residents for personal care maintain water temperatures between 105 F to 120 F.
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 temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by: Licensee did not ensure that water temperatures in faucets used by residents for personal care had water temperatures which ranged between 105 F to 120 F. LPA Marrufo observed 3 out of 3 bathroom faucets had water temperatures above 120 F, which poses an immediate safety risk to residents in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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