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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206707
Report Date: 07/26/2022
Date Signed: 07/26/2022 10:24:33 AM

Document Has Been Signed on 07/26/2022 10:24 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MONSEVAIS RESIDENTIAL FACILITYFACILITY NUMBER:
107206707
ADMINISTRATOR:LYN MONSEVAISFACILITY TYPE:
735
ADDRESS:6622 N NANTUCKET AVETELEPHONE:
(559) 374-6000
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 4DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Morgan Cassle, StaffTIME COMPLETED:
10:45 AM
NARRATIVE
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On 7/26/22 at 8:28 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an annual inspection. LPA explained reason for inspection and was granted entry. Administrator (ADM) Lyn Monsevais was unavailable for the inspection but was available by telephone. ADM gave permission for staff to sign today's report. A tour of the facility was conducted. COVID-19 guidelines are in place. Facility has one main entrance/exit point.

Facility was observed clean and without any obstructions. Hand sanitizer was readily available to residents and visitors. Bedrooms were checked. Two residents share one room and two other residents have private rooms. LPA checked residents’ medications and observed the month's supply. Cleaning and PPE supplies were checked. Majority of PPE supply is kept at the off-site facility office. Residents files have updated emergency contact information. Administrator certification is valid.

The following deficiencies were cited:

1. One bottle of bleach observed accessible in cabinet under kitchen sink and one bottle of bleach observed accessible in backyard, under the patio.

2. Sliding door bottom panel observed taped and coming away from track. One door and one broken chair observed on walkway of backyard. Bedroom #1 window curtain rod observed bent. Bedroom #2 observed with strong urine odor. Living room rug observed with three of four corners rolled up.

Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.



Exit interview conducted. A copy of this report and appeal rights were given to staff Morgan Cassle, whose signature confirms receipt of this report. Plan of Correction made with ADM via telephone.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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 3
Document Has Been Signed on 07/26/2022 10:24 AM - It Cannot Be Edited


Created By: Malia Thao On 07/26/2022 at 09:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MONSEVAIS RESIDENTIAL FACILITY
FACILITY NUMBER: 107206707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. One bottle of bleach observed accessible in cabinet under kitchen sink and one bottle of bleach observed accessible in backyard under the patio, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
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Staff immediately removed the two bottles of bleach and locked them into the hall closet where cleaners are kept. POC cleared during the inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/26/2022 10:24 AM - It Cannot Be Edited


Created By: Malia Thao On 07/26/2022 at 09:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MONSEVAIS RESIDENTIAL FACILITY
FACILITY NUMBER: 107206707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observations and interview, the licensee did not comply with the section cited above. Sliding door bottom panel observed taped and coming away from track, one door and one broken chair observed on walkway of backyard, bedroom #1 window curtain rod observed bent, bedroom #2 observed with strong urine odor, and living room rug observed with three of four corners rolled up, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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Administrator will remove bottom panel of sliding door and smooth the edges; door, broken chair, and living room rug will be removed from the facility; bedroom #1 curtain rod will be replaced; and bedroom #2's carpet will be cleaned and mattress will be replaced by POC due date. LPA will return for a POC visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


LIC809 (FAS) - (06/04)
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