445202356-3-11-2022-26-AS-KHOS-CD7JNZ-20220405071245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202356
Report Date: 03/11/2022
Date Signed: 03/11/2022 12:23:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2021 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20210831111600

FACILITY NAME:	MONTECITO MANOR		FACILITY NUMBER:	445202356
ADMINISTRATOR:	JOLENE SICLEY		FACILITY TYPE:	740
ADDRESS:	311 MONTECITO AVE.		TELEPHONE:	(831) 724-3055
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	85	CENSUS: 54	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ivonne Sanchez		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility has a rat infestation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the finding to the above allegation. LPA met with Ivonne Sanchez Facility Manager.

LPA interviewed 5 staff and 7 residents and reviewed facility maintenance records for January 2021 through February 2022.

5 of 5 staff interviewed stated that there were no instances of rodents inside the facility. 2 of 5 staff noted rodents in the back patio and garbage container area. This was addressed by maintenance and no further issues arose. During site visits on 9/9/2021 and today's visit 3/11/2022 LPA did not observe any signs of rodent or pest infestation. Maintenance records reviewed indicate the facility was maintaining monthly pest control services and no issues noted with regards to rodents.

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 26-AS-20210831111600

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: MONTECITO MANOR	FACILITY NUMBER: 445202356
	VISIT DATE: 03/11/2022

NARRATIVE

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6 of 7 residents interviewed stated they never saw any rodents inside the facility. The facility is well maintained. 1 of 7 residents observed 2 live rodents in the back yard but none in the facility. R7 stated maintenance took care of the problem.

This Department has investigated the complaint allegation listed. Based on interviews, review of records, and observations, the Department has found that the complaint allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

LPA reviewed this report with Ivonne Sanchez Facility Manager and a copy of this report provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2021 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20210831111600

FACILITY NAME:	MONTECITO MANOR		FACILITY NUMBER:	445202356
ADMINISTRATOR:	JOLENE SICLEY		FACILITY TYPE:	740
ADDRESS:	311 MONTECITO AVE.		TELEPHONE:	(831) 724-3055
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	85	CENSUS: 54	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ivonne Sanchez		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff withheld cigarettes from resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the finding to the above allegation. LPA met with Ivonne Sanchez Facility Manager.

LPA interviewed 5 staff and 7 residents and review facility records to include Admission Agreement.

3 of 5 staff stated that cigarettes are distributed per schedule and staff did not withhold cigarettes from residents. The other 2 staff job tasks do not involve cigarette distribution.

6 of 7 residents stated staff did not withhold cigarettes. 1 of 7 residents R7 stated R7 was to receive 2 cigarettes each scheduled time instead of one. R7 stated staff would not give R7 2 cigarettes when requested. R7 stated this was resolved. S1 stated that there was a mis-communication with staff regarding R7's allowed number of cigarettes. S1 confirmed this was corrected.

Page 1 of 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20210831111600

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: MONTECITO MANOR	FACILITY NUMBER: 445202356
	VISIT DATE: 03/11/2022

NARRATIVE

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Admission Agreement was reviewed and states: "Montecito Manor is a NO SMOKING BUILDING. Smoking is permitted outside the building. Management must keep the cigarettes and matches for the safety of residents".

This Department has investigated the complaint allegation listed. Based on interviews and review of records, the Department has found that although the allegations listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

LPA reviewed this report with Ivonne Sanchez Facility Manager and a copy of this report provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

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