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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803655
Report Date: 12/17/2021
Date Signed: 12/17/2021 11:26:03 AM

Document Has Been Signed on 12/17/2021 11:26 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MONTE VERDE HOMEFACILITY NUMBER:
496803655
ADMINISTRATOR:TANEDO, JANET NFACILITY TYPE:
734
ADDRESS:5838 MONTE VERDE DRIVETELEPHONE:
(510) 366-4031
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 5CENSUS: 5DATE:
12/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:RN, Guadalupe LoeraTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced at approximately 9:15 AM to conduct a Required-1 Year inspection of this facility. The inspection was focused on the infection control practices of the facility. Facility has a COVID mitigation plan which was submitted and reviewed by Community Care Licensing. LPA met with RN, Guadalupe Loera. There are currently 5 clients in care.

Upon arrival LPA observed COVID postings at the front door. LPA was initially greeted by staff who directed LPA to answer screening questions and sign in on visitor log. Facility has a wall mounted touchless thermometer for screening visitors. Staff are also required to sign in and screen upon starting their shift. Client temperatures are monitored each shift.

All clients were observed participating in a virtual day program in the living room upon arrival which included stories and exercises. LPA toured facility with RN and observed 5 private client bedrooms and 2 bathrooms. Facility was clean, a comfortable temperature and exits were free from obstructions. Hand sanitizer and COVID postings were observed throughout the facility. Due to private bedrooms clients could isolate in their bedrooms if necessary. LPA confirmed that facility has the necessary personal protective equipment (PPE) to support a client in isolation. RN indicated that North Bay Regional Center (NBRC) has been providing facility with additional PPE.

High touch surface areas are disinfected daily. LPA reviewed daily sanitizing and cleaning log which was found to be kept current. LPA also reviewed 2 out of 5 client files. Client reviewed individualized health care plans which included individualized descriptions of client abilities to perform to activities of daily living. Plans were signed in October.

All clients have received their COVID booster shot as well as the flu shot. Staff have also all received at least two doses of a COVID vaccine and their flu shot.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: MONTE VERDE HOME
FACILITY NUMBER: 496803655
VISIT DATE: 12/17/2021
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Staff have been N95 fit tested by qualified RN. Facility has an available COVID 19 Preparedness Emergency Plan binder with training resources. Facility is not currently conducting weekly surveillance testing due to vaccination rate. Facility conducts testing as needed.

Exit interview conducted with Guadalupe Loera and a copy of this report was printed for the licensee.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC809 (FAS) - (06/04)
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