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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200680
Report Date: 07/23/2024
Date Signed: 07/23/2024 05:21:31 PM

Document Has Been Signed on 07/23/2024 05:21 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/
DIRECTOR:		AUDREY ANN SALVADORFACILITY TYPE:
735
ADDRESS:998 A-B MONTE BELLO DRTELEPHONE:
(408) 847-9999
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Audrey Ann SalvadorTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required 1 year inspection. LPA met with Administrator, Audrey Ann Salvador.

LPA toured the facility to include the 5 resident bedrooms, staff bedrooms, bathrooms, kitchens, living rooms, 1 out of 2 garage, and backyard. LPA was unable to observed the garage in unit B because the Administrator did not have the code and key to the garage at the time.

From 11:00AM - 2:00PM, there were 2 staff and 1 resident present during visit. After 2:00PM, there were 4 staff present to 6 residents. All staff present are fingerprint cleared and associated to the facility.

Fire exit routes were free of obstruction. Facility temperature maintained at 74 degrees Fahrenheit. Fire extinguisher purchased on 05/2024. Carbon monoxide detector observed present in the facility. Sharp objects, chemicals, disinfectants, and medications observed locked. Facility has at least 2 days worth of perishables and 7 days worth of nonperishable foods. Refrigerator temperature maintained at 26 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Resident bedrooms contains adequate lighting, a bed, linens, dresser, and night stands. Bathroom hot water temperature in unit B maintained at 136 degrees Fahrenheit. Administrator was advised. Bathroom hot water temperature in unit A maintained at 126 degrees Fahrenheit.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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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 BELLO ADULT CARE HOME
FACILITY NUMBER: 435200680
VISIT DATE: 07/23/2024
NARRATIVE
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LPA reviewed 3 resident files. LPA observed 2 out of 3 resident's appraisal/needs and services plan were not signed by the resident and/or resident's responsible party. LPA observed 1 out of 3 resident's admission agreement is not signed by the resident's responsible party. Administrator was advised. 3 out of 3 resident's centrally stored medication and P&I records are maintained. LPA reviewed 3 staff files to include training. Staff files observed to be maintained. 3 out of 3 staff members has an active first aid certification.

Facility has an emergency disaster plan. Emergency lighting and batteries are maintained in the facility. Facility staff are conducting the emergency drills quarterly.

Documents obtained during visit to include the surety bond and LIC400.

LPA requested the facility's lease agreement by 07/24/2024.

During visit, Licensee paid the facility's annual fee.

Deficiencies were 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: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/23/2024 05:21 PM - It Cannot Be Edited


Created By: Christine Dolores On 07/23/2024 at 02:49 PM
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: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above wherein the hot water temperature is maintained at 126 and 136 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee will provide a picture proof of the hot water temperature in unit A and unit B. Licensee will submit the pictures to LPA Dolores via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2024 05:21 PM - It Cannot Be Edited


Created By: Christine Dolores On 07/23/2024 at 02:57 PM
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: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not ensure 2 out of 3 resident's appraisal/needs and services plan is signed by the resident's responsible party and 1 out of 3 resident's admission agreement is signed by the resident's respoinsible party which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2024
Plan of Correction
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Licensee will obtain a signature for 2 out of 3 resident's appraisal/needs and services plan and 1 out of 3 resident's admission agreement. Licensee will send the signed documents to LPA Dolores via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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