445202356-1-29-2025-26-AS-DMAO-DDD2EP-20250128162017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202356
Report Date: 01/28/2025
Date Signed: 01/29/2025 09:59:40 AM

Document Has Been Signed on 01/29/2025 09:59 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	MONTECITO MANOR		FACILITY NUMBER:	445202356
ADMINISTRATOR/ DIRECTOR:	JOLENE SICLEY		FACILITY TYPE:	740
ADDRESS:	311 MONTECITO AVE.		TELEPHONE:	(831) 724-3055
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY: 85	TOTAL ENROLLED CHILDREN: 0	CENSUS: 53	DATE:	01/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Jolene Sicley		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Jolene Sicley. During visit, LPA toured the facility inside and out. LPA toured three out of three kitchen areas and food storage areas. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed locked storage areas for cleaning supplies. LPA reviewed the first aid kit during visit and found it to be complete. During visit, staff tested the centralized smoke detector system and LPA found it to function properly when tested. Staff tested carbon monoxide detectors located throughout the facility and all carbon monoxide detectors functioned properly when tested. LPA observed two bathrooms in the memory care wing and two bathrooms in the assisted living wing. Two out of two memory care bathroom sinks had water temperatures at 107 F. One of the assisted living bathrooms had a sink with water temperature at 95 F and the other assisted living bathroom sink had water temperature at 103 F. During visit, staff told LPA that two out of three facility water boilers had malfunctioned and staff were awaiting on replacement parts to be delivered and installed. Staff showed LPA invoices for the replacement parts and services that have been scheduled for the water boilers. LPA observed that all bathrooms had available soap and paper towels and working lights. See LIC809-C for more information. Page 1 of 2.

Sarah Yip	TELEPHONE: (408) 324-2131
David Marrufo	TELEPHONE: (650) 380-0519
	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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 2

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: 01/28/2025

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LPA toured ten resident bedrooms and observed each bedroom to have available bedding and clothing storage areas and working lights. LPA toured the outside areas and observed the exits to be clear of obstructions.

LPA reviewed the resident records for seven residents and found them to be complete. LPA reviewed the staff records for seven staff and found them to be complete. LPA reviewed the Centrally Stored Medication and Destruction Records and Personal and Incidental Money Logs for seven residents and found them to be complete and balanced.

An Advisory Note was issued. See LIC9102 for more information.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator Jolene Sicley and a copy of this report was provided.

Page 2 of 2.

END REPORT

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

Page: 2 of 2