Monteverde Manor Iii

On 05/06/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with caregiver KimIvanWilfred Budy and explained the purpose of today's visit. Currently there are 6 residents present and 2 caregivers. The facility is licensed for age range 60 years and over. All are approved to be non-ambulatory. Hospice waiver for 3 residents. Currently there are no residents on hospice per staff interviewed. The facility ambient temperature is comfortable. There are Required postings are in place observed in main dining area. Water temperature is tested in the common hallway full bathroom measuring as 135F near room 6. Additional bathroom water temperature is measured at 135F in another full bathroom near room 4. Cleaning supplies are observed to be locked in the garage primarily. Facility knives are observed to be locked in the kitchen in a drawer adjacent to the cooking range and stove. Facility food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. The garage has additional refrigerators with staff and resident food and additional emergency food supplies. Laundry area is observed in the garage as well and is fully operational. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. There is a locked storage shed in the backyard that contains garden supplies and furniture. Smoke detectors and carbon monoxide detectors are located through out the facility. LPA observed 3 fire extinguishers are observed in the facility. Both with inspection dates of 10/04/2024. Both are charged and ready for use. Facility conducts emergency drill quarterly. The last drill that was conducted is logged 04/30/2025. Linens are in place for resident in care. Continued on next page... 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 26 27 28 29 30 31 32 Page 2 LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications are current, locked, and logged appropriately. First aid kit is present. There are two bathrooms, one is used as the main shower for residents, with grab bars and non-skid mats. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed 4 resident files and 4 staff files on this day. LPA observed that residents 1 through 4 do not have doctor orders for half bed rails or full bed rails. Staff training records are observed to be current and in place. Administrator certificate for Dino Martin is observed as current expiring 12/18/2024. LPA informed facility that annuals fees are overdue as of today's visit. The following updated items are to be received by 05/13/2025 : • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC402 Surety bond and Copy of active bond • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease Report is reviewed with KimIvanWilfred Budy . A copy of this report is provided to the facility. Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Technical advisory issued on attached LIC9102 Civil penalty is assessed due to a repeat violation which equals to $250. See attached LIC421FC(7/17)

On May 24, 2024 at 2:00 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required visit. LPA Calandra was greeted by Benjie Guce and Dave Enaro, Caregivers and explained the purpose of his visit. Dino Martin, Licensee/Administrator arrived later during the visit. LPA Calandra toured the physical plant. This is a 1-story building with 6 bedrooms and 2 bathrooms. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. All bedrooms were sufficiently lit and had the required furniture. All bathrooms had the required grab bars and anti-skid floor mats. The Fire extinguishers were observed to be fully charged and last checked on 10/9/2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. No hazards or obstructions were observed in the back and front yards, hallways, and other areas of the facility. The facility's fire and carbon monoxide detectors were observed to be in working condition. The first aid kit was observed to have all required supplies. The washer and dryer were observed to be in working condition. All knives, sharp objects, soap, and detergents were observed to be locked and in-accessible to persons in care. LPA Calandra reviewed 4 staff records and 5 client records. All were observed to be complete. A Type A citation was provided for having faucets that delivered hot water measuring above 125 degrees Fahrenheit. The Annual Inspection will be completed at a later date. 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 26 27 28 29 30 31 32 This report was reviewed with Dave Enero, Caregiver. A copy of the report along with appeal rights was left at the facility.

On August 1, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted on the front door. LPA met with Administrator, Dino Martin and explained the purpose of the visit. Administrator was able to provide LPA screening log documentation for visitors, staff and residents. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 6 resident bedrooms, 1 staff room, and 3 full bathrooms. LPA observed all resident bedrooms to be private rooms. Bathrooms were observed to be equipped with liquid soap, paper towels, and a hand washing sign. LPA advised administrator to ensure trash cans are covered with a lid. Infection control practices are present: entry procedures, daily monitoring for residents and staff, COVID-19 signage posted throughout the facility, and 30-day PPE supply. LPA toured the living room and dining room and it was clear and free from any tripping hazards. A comfortable temperature was maintained, lighting is sufficient for comfort. LPA toured the kitchen, medications, toxins and sharps are stored appropriately and inaccessible to residents. LPA observed 2 day perishable and 7 day non-perishable present. First aid kit was observed to be completed. Extra linen was observed to be present. LPA observed the staff room which lead to the garage. The garage was observed to have extra food supply. Washer and dryer was observed to be in good working condition. LPA observed an attic above the garage with clothes and boxes. According to the Administrator, no staff are sleeping in the attic, however is looking into obtaining fire clearance for the attic to be used as a staff room. (CONT. to 809C) 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 26 27 28 29 30 31 32 It was found during the visit that a staff member (S1) was not associated to the facility. LPA reviewed the staff roster with the Administrator and confirmed that S1 is not associated to the facility but does have a fingerprint clearance. This violation results in an immediate civil penalty of $100.00. LPA requests the following forms to be submitted to CCLD by 8/8/22: LIC308 Designation of Administrative Responsibility LIC500 Personnel Report LIC610E Emergency Disaster Plan Administrator Certificate Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed. This report was reviewed and discussed with Administrator, and a copy is provided with appeal rights.