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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803655
Report Date: 01/17/2024
Date Signed: 01/17/2024 12:28:12 PM

Document Has Been Signed on 01/17/2024 12:28 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
SANTA ROSA RO, 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: 5DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Janet Tanedo,AdministratorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by LPT. Janet Tanedo, Administrator arrived later at approximately 9:00am. Facility contact information was reviewed.


At approximately 9:00am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. Kitchen cabinet containing cleaning supplies was locked. Cleaning and laundry supplies located in the garage were secured and locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured respectively at 107.5 and 116.9 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 07/27/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 01/04/2024. Facility has a backup generator for use during a power outage.

At approximately 10:00am LPA and Admin did a spot check of cash resources and cash records for four [4] out of four [4] clients. All resources logged accurately.

At approximately 10:15am LPA conducted a review of five [5] out of five [5] resident files and five [5] staff records. All required documentation present and current. Resident R1 currently being assessed for wheelchair needs, Admin to send over exception request for any needed postural supports.

Report continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MONTE VERDE HOME
FACILITY NUMBER: 496803655
VISIT DATE: 01/17/2024
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Continued from 809...

At approximately 12:00pm LPA and LPT conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in the work office area next to the kitchen.

Janet Tanedo, Administrator Certificate 6041168735 expires 10/2024. All fees are current as of this time. Gave PIN to Admin for payment due by 2/17/2024.

LPA and Admin discussed facility's Infection Control Plan and Emergency Disaster Plan. No updates needed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

Copy of Lease
Surety Bond ($4000)
Evidence of Liability Insurance

Exit interview conducted with LPT and a copy of this report was given.

No deficiencies cited during this inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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