496803884-7-29-2020-21-AS-KMOA-BRYL87-20200729083125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803884
Report Date: 07/28/2020
Date Signed: 07/29/2020 08:32:00 AM

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 REST HOME		FACILITY NUMBER:	496803884
ADMINISTRATOR:	LATIMER, CAROLINE		FACILITY TYPE:	740
ADDRESS:	5570 MONTE VERDE DR		TELEPHONE:	(707) 775-9327
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	6	CENSUS: 6	DATE:	07/28/2020
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Caroline Latimer, Licensee		TIME COMPLETED:	01:30 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) Mota conducted a tele-visit inspection on 7/28/2020 at approximately 11:30 AM to conduct a post licensing visit. LPA is conducting a tele-visit with Licensee, Caroline Latimer. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit. Currently there are 6 residents in care none of which are on hospice and some who have a diagnosis of dementia. Auditory device's were observed functioning at the time of the tele-visit. The amount of fresh and nonperishable foods appeared to be within regulation. Toxins appeared to be in a locked cabinet under the kitchen sink. Sharps are kept locked in a separate kitchen cabinet. Medications are kept in a locked closet near the front door. Licensee was able to provide. Food is available for residents any time of the day. Bathrooms were equipped with necessary grab bars and non-slip floors/mats and appeared to have sufficient hygiene products. Fire extinguishers inspected were charged and dated 8/2/2019. Smoke detectors were tested and inspected by City of Santa Rosa on 5/27/2020 and were documented as being in compliance. Carbon monoxide detector was inspected. Licensee stated a disaster drill has not been completed within the last quarter. (Technical Advisory issued). LPA provided Licensee with copy of regulation 1569.695. The Fire Safety Inspection was conducted on 12/31/2019. Fire clearance was granted by Santa Rosa Fire Department for 2 ambulatory and 4 non-ambulatory residents. LPA observed required postings (LTCO, CCL Complaint poster) in addition to COVID-19 required visitation postings. Facility is screening essential visitors at the front door which includes taking temperatures. Staff were observed wearing face masks. Facility states it has sufficient PPE at this time. Continued on 809-C

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Kimberley Mota	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020

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 REST HOME	FACILITY NUMBER: 496803884
	VISIT DATE: 07/28/2020

NARRATIVE

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LPA did not review resident files as current shelter in place only allows for essential medical visits at this time. LPA and Licensee discussed the need to have records current and up to date.

LPA reviewed 1 staff record and found that staff had current 1st aid / CPR.

Caroline Latimer Administrator License 6052028740 expires 5/7/2021.

Licensee and LPA discussed PIN 20-23, specifically visitation, importance of screening and hand sanitation, as well as planned activities. In addition, LPA and Licensee discussed CCL's future use of the Everbridge alert system and the importance of responding to email prompts should a need arise.

No deficiencies cited at today's virtual inspection.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Kimberley Mota	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020

LIC809 (FAS) - (06/04)

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