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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202549
Report Date: 10/13/2021
Date Signed: 10/14/2021 10:09:07 AM

Document Has Been Signed on 10/14/2021 10:09 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MONTEREY BAY GUEST HOME #2FACILITY NUMBER:
275202549
ADMINISTRATOR:INNEH, EMMANUELFACILITY TYPE:
735
ADDRESS:645 WILLIAMS ROADTELEPHONE:
(831) 975-4970
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY: 40CENSUS: 37DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Emmanuel InnehTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/13/2021 at 02:21pm. LPA met with facility administrator Emmanuel Inneh (Admin).

Upon entering the facility, LPA noted that the fire alarm lights were blinking, and that mattresses were lining the west hall of the facility. LPA asked the facility Admin if they were currently spraying for bedbugs. Admin stated that they were and that the exterminator had arrived at about 12:00pm. Admin further clarified that the exterminator had sprayed the beds in the Eastern hall already. In interviews with facility residents conducted from 4:00pm to 4:21pm, 0 out of 5 residents stated that they had been bitten by bed bugs.

LPA began the tour at 02:32pm. Admin asked LPA to sign in, but the sign in process did not include recording temperature or screening for symptoms. Facility noted to have 30-days supply of PPE. Facility public bathrooms were not noted to contain any paper towels, but did have handwashing signs posted and lidded trash cans. Social distancing signs observed to be posted throughout the facility.

In room 17 jack and jill bathroom, LPA observed clogged toilet bowl filled with toilet paper, urine, and feces. Room 17 observed to be missing door knob, with shirt stuffed where doorknob would normally be. In restroom connected to room 15, LPA observed shower to have black and red mold, shower door also had trouble opening and closing. In jack and jill bathroom connected to room 8, LPA observed full garbage can and sink with cold water knob missing. Sink cabinet was also observed to be broken off hinges.

Deficiencies were cited and advisory noted were issued. See 809-D for details. This report was reviewed with Administrator Emmanuel Inneh and a copy of this signed report with appeal notes was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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Document Has Been Signed on 10/14/2021 10:09 AM - It Cannot Be Edited


Created By: Ryker Heberle On 10/13/2021 at 03:54 PM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MONTEREY BAY GUEST HOME #2
FACILITY NUMBER: 275202549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
80087(a) - Building and Grounds - 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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Based on observation, the licensee did not comply with the section cited above in 3 out of 11 bathrooms as evidenced by a shower containing mold, a toilet clogged with waste, and a sink in disrepair, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2021
Plan of Correction
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Licensee cleaned the clogged toilet and was in the process of cleaning the shower during visit. Licensee will send photographs of cleaned and repaired areas upon purchase and installation of new parts.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2021 10:09 AM - It Cannot Be Edited


Created By: Ryker Heberle On 10/13/2021 at 04:06 PM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MONTEREY BAY GUEST HOME #2
FACILITY NUMBER: 275202549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)(1)(E)
80061(b)(1)(E) - Reporting Requirements - Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours.
(1) Events reported shall include the following:
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. 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 by not submitting an unusual incient report regarding spraying facility for bed bugs over the course of 3 days, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2021
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021


LIC809 (FAS) - (06/04)
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