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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200680
Report Date: 07/28/2025
Date Signed: 07/28/2025 04:02:40 PM

Document Has Been Signed on 07/28/2025 04:02 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:
07/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Audrey Ann SalvadorTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator, Audrey Ann Salvador.

During visit, LPA toured the facility to include the resident bedrooms, bathroom, staff rooms, living rooms, kitchen, garage and backyard. LPA observed 2 residents to 2 staff members present. All staff were fingerprint cleared and associated to the facility. All fire exit routes were free and clear of obstruction.

Facility temperature was maintained at 65 degrees (unit B) and 70 degrees F (unit A). The residents were sitting in unit B, where the facility temperature was set to 65 degrees F. Staff stated they lowered the temperature because the staff were feeling very warm. LPA advised to ensure the facility temperature is always set to at least 68 degrees F. Staff immediately turned up the temperature to 69 degrees F.

Resident bedrooms equipped with proper furniture, linens and adequate lighting. Bathroom hot water temperature in unit B maintained at 104 degrees F and unit A hot water temperature maintained at 138.6 degrees F. Administrator was advised to ensure the hot water temperature is maintained between 105 - 120 degrees F. Facility is equipped with a fire extinguisher, and operable carbon monoxide detector/smoke detector. See LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/28/2025
NARRATIVE
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Facility observed with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 28 degrees F. Freezer temperature maintained at 0 degrees F. Sharp objects, chemicals, disinfectants and medications locked and stored in separate location from the food supply.

Around 11:00am, LPA observed staff serve a resident only a plate of broccoli for lunch without offering grains, protein and other options. Based on review of the resident's file, the resident has a meal plan prepared by a dietician which indicates the serving of grains, meat, vegetables, and fruits. The Administrator was advised to ensure all residents are prepared meal serving based on the USDA basic food group plan. Administrator stated understanding.

LPA reviewed 3 resident files. 3 out of 3 resident files observed complete and up-to-date. 3 resident's centrally stored medications and centrally stored medication records were inspected with ADM. 3 out of 3 residents P&I funds was counted with the ADM. All the money was accounted for and being logged.

LPA reviewed 3 staff files. 3 out of 3 staff files observed complete to include a 1st aid certification, fingerprint clearance, health screening TB result, job application, and annual training.

Facility has an emergency disaster plan. Emergency drills are being completed quarterly and the last drill was completed in June 2025. Facility has emergency lighting and batteries.

Documents were requested by 08/04/2025 to include the following:
- Administrator Certificate
- LIC500
- Updated Emergency Disaster Plan

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.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/28/2025 04:02 PM - It Cannot Be Edited


Created By: Christine Kabariti On 07/28/2025 at 03:13 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: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(a)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above wherein the facility temperature was observed at 65 degrees F in unit B which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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Licensee will place a sign next to the themostat to remind staff of the Title 22 regulation and provide an in-service training. Licensee will submit a photograph of the sign next to both thermostats (unit a and unit b) and the in-service training document to LPA Kabariti via email by POC due date.
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 and interview, the licensee did not comply with the section cited above wherein the hot water temperature in unit a was observed at 138.6 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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Licensee will create a hot water log and train staff to monitor the hot water temperature in unit a and unit b. Licensee will send the hot water log and in-service training document to LPA Kabariti via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2025 04:02 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Christine Kabariti On 07/28/2025 at 03:13 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: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type B
Section Cited
CCR
80076(a)(1)
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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 resident was not provided at least 1/3 of the servings recommended in the USDA basic food group plan as LPA observed a resident was provided only a plate of broccoli for lunch which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
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Licensee will create a sample meal plan for each resident that has a special diet. Licensee will also provide training to staff regarding the serving recommendations in the USDA Basic Food Group Plan and resident's special diet plan. Licensee will submit the sample meal plan and in-service training document to LPA Kabariti 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.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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