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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202356
Report Date: 03/11/2022
Date Signed: 04/18/2022 11:40:47 AM

Document Has Been Signed on 04/18/2022 11:40 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
CCLD Regional Office,
, CA
FACILITY NAME:MONTECITO MANORFACILITY NUMBER:
445202356
ADMINISTRATOR:JOLENE SICLEYFACILITY TYPE:
740
ADDRESS:311 MONTECITO AVE.TELEPHONE:
(831) 724-3055
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 85CENSUS: 54DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ivonne SanchezTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Ivonne Sanchez Facility Manager.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked medication room.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products. Hand sanitizer available to visitors and residents. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Visitor Policy, Face Coverings Required For Entry, Limit Family Gatherings, Tips for Reducing COVID 19 Indoors, Are You Feeling Ill and social distancing.

LPA reviewed the facility policies and procedures to include screening, visitation, masking, isolation and disinfecting,

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Ivonne Sanchez Facility Manager and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
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.

LIC809 (FAS) - (06/04)
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