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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803655
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:44:37 PM

Document Has Been Signed on 05/09/2023 02:44 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 4DATE:
05/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Janet TanedoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Monte Verde Home for the purpose of conducting a Case Management-Incident Inspection. LPA was greeted at the door by Administrator, Janet Tanedo, and was granted access into the facility.

During the Case Management-Incident Inspection, LPA interviewed the Administrator and also requested the following documents to be reviewed:

-Discharge paperwork
-POLST document
-LIC 602

Also during this Case Management-Incident Inspection, LPA reviewed the above documents.

No deficiencies were observed or cited during today's Case Management-Incident inspection. Exit interview was conducted and a copy of this report was given to the facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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