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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200680
Report Date: 07/22/2022
Date Signed: 07/22/2022 02:49:32 PM

Document Has Been Signed on 07/22/2022 02:49 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 BELLO ADULT CARE HOMEFACILITY NUMBER:
435200680
ADMINISTRATOR:DULCE ROSE CERAFACILITY TYPE:
735
ADDRESS:998 A-B MONTE BELLO DRTELEPHONE:
(408) 847-9999
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:DULCE ROSE CERATIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection to focus on infection control. LPA met with Administrator, Dulce Rose Cera.

During visit, LPA toured the facility to include the living rooms, kitchens, bathrooms, resident rooms, and backyard.

Facility has a designated entry point for symptom screening and temperature check for staff, visitors, and residents. LPA advised Administrator to update facility's screening log to include all symptoms of COVID, questions of COVID-19 exposure, and diagnosis. Hand sanitizer available upon entry. Bathrooms supplies with hygiene products, paper supplies, and hand-washing sign. LPA advised to place a hand washing sign in all hand washing areas. Trash cans observed with a lid. LPA observed facility's Personal Protective Equipment (PPE) supplies. Facility staff clean and disinfect multiple times daily and as needed. The following posters observed to include required mask and symptoms of COVID. LPA reviewed facility's policies and procedures to isolation, screening, and infection control training. Staff are not N95 fit-tested.

LPA will provide the facility with COVID-19 resources. The following documents requested: LIC500, LIC610D, and Administrator Certificate by 07/29/2022.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Dulce Rose Cera and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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