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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202356
Report Date: 01/31/2024
Date Signed: 01/31/2024 04:53:38 PM


Document Has Been Signed on 01/31/2024 04:53 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:MONTECITO MANORFACILITY NUMBER:
445202356
ADMINISTRATOR:JOLENE SICLEYFACILITY TYPE:
740
ADDRESS:311 MONTECITO AVE.TELEPHONE:
(831) 724-3055
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:85CENSUS: 56DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jolene SicleyTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Jolene Sicley.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured 3 out of 3 facility kitchens. The kitchens had a perishable food supply of at least two days and a non-perishable food supply of at least 7 days.

LPA toured 10 resident bedrooms and observed each bedroom to have available bedding and clothing storage areas as well as working lights. LPA toured 2 out of 2 hallway bathrooms and observed them to have available soap and paper towels and water temperature between 111-114 F.

During visit, LPA Marrufo tested the facility smoke alarm system. During the test, the emergency strobe lights did not flash in any parts of the building and only a faint sound could be heard in the main lobby area. During visit, technicians visited the facility and repaired the alarm system. A second test was conducted and LPA observed strobe lights and alarm sounds in all areas of the facility building.

The outdoor area was toured and the exits were found to be clear of obstructions.

LPA Marrufo reviewed the Centrally Stored Medication Logs and Resident Records for 5 residents and found them to be complete. LPA reviewed staff records for 5 staff and found them to be complete. LPA reviewed the Personal and Incidental Money Log for residents R1-R3. R1 was missing $191.32, R2 did not have a Personal and Incidental Money Log but had $47 that the facility was safeguarding for R2, and R3 had $280, but R3's Personal and Incidental Money Log stated R3 was only supposed to have $98.

See LIC809-C for more information.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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 3


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: MONTECITO MANOR
FACILITY NUMBER: 445202356
VISIT DATE: 01/31/2024
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A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information.

This report was reviewed with Administrator Jolene Sicley and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/31/2024 04:53 PM - It Cannot Be Edited

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: MONTECITO MANOR
FACILITY NUMBER: 445202356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87217(g)(1)
(g) Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following: (1) Records of residents' cash resources maintained as a drawing account shall include a ledger accounting (columns for income, disbursements and balance) for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 resident Personal and Incidental Money Logs, of which two residents did not have a current account and 1 resident did not have any Personal and Incidental Money Log, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2024
Plan of Correction
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Licensee agrees to audit all Personal and Incidental Money Logs and ensure they are properly accounted for and kept current by POC date. Licensee also agrees to develop a policy to ensure that safeguarded resident money will be accounted for and kept current in the future and submit the policy to CCL by POC 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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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