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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200680
Report Date: 11/19/2024
Date Signed: 11/19/2024 11:15:23 AM

Document Has Been Signed on 11/19/2024 11:15 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 BELLO ADULT CARE HOMEFACILITY NUMBER:
435200680
ADMINISTRATOR/
DIRECTOR:		AUDREY ANN SALVADORFACILITY TYPE:
735
ADDRESS:998 A-B MONTE BELLO DRTELEPHONE:
(408) 847-9999
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 5DATE:
11/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Audrey Ann SalvadorTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit based on violations observed during the complaint investigation for control number 26-AS-20240520083627. LPA met with Administrator, Audrey Ann Salvador.

During the complaint investigation, it was found that staff are not trained on handling resident (R1)’s inhalation assistive device. Based on review of R1’s restricted health condition care plan, it states that staff training should be kept up to date and reviewed / completed annually. It is also stated that care plan actions [use of the inhalation assistive device] can only be performed by trained staff.

The Administrator stated that the facility staff are in the process of obtaining annual training on R1’s restricted health condition care plan / inhalation assistive device. The Administrator was unable to provide the annual training documentation for staff who are handling R1’s inhalation assistive device.

The Administrator was unable to produce documentation to show that R1’s doctor was notified of R1’s change of condition on 05/12/2024 and 05/13/2024.

Deficiencies was cited per California Code of regulations, Title 22. See LIC809-D.

This report was reviewed with Administrator, Audrey Ann Salvador and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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 11/19/2024 11:15 AM - It Cannot Be Edited


Created By: Christine Dolores On 11/19/2024 at 09:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MONTE BELLO ADULT CARE HOME
FACILITY NUMBER: 435200680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2024
Section Cited
CCR
80092.3(a)(6)

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(a) A licensee of an adult CCF may accept or retain a client who requires the use of an inhalation-assistive device if all of the following conditions are met: (6) The licensee ensures that facility staff have the knowledge of and ability to care for the device. This requirement is not met as evidenced by:
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Licensee is currently working the the facility's RN consultant to update R1's restricted health condition care plan.
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Based on interview, record review and observation the licensee did not comply with the section cited wherein the licensee did not ensure staff were provided annual training on R1’s inhalation assistive device prior to use which poses an immediate health, safety and personal rights risk to persons in care.
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Licensee will follow-up with the RN consultant on a tentative date for staff training and submit the plan for staff training to LPA Dolores by POC due date of 11/20/2024.
Type A
11/20/2024
Section Cited
CCR85075.4(c)

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(c) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any. This requirement is not met as evidenced by:
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Licensee states if there is a change of condition they will inform the resident's doctor and authorized representative and document the encounter. Licensee will submit this statement in writing to LPA Dolores
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Based on interview, record review, and observation the licensee did not comply with the section cited above wherein the licensee did not ensure to inform R1’s physician of R1’s change of condition on 05/12/2024 and 05/13/2024 which poses an immediate health, safety, and personal rights risk to persons in care.
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by POC due date of 11/20/2024.
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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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