<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424970
Report Date: 03/18/2022
Date Signed: 03/18/2022 10:39:06 AM

Document Has Been Signed on 03/18/2022 10:39 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MONTAGE MANORFACILITY NUMBER:
336424970
ADMINISTRATOR:CYNDY ZAECHFACILITY TYPE:
740
ADDRESS:69-920 MATISSE RDTELEPHONE:
(760) 699-5090
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 6DATE:
03/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Vanessa Franco - Facility ManagerTIME COMPLETED:
10:45 AM
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) Crystal Colvin arrived at the facility unannounced for the purpose of conducting a Case Management Inspection to follow up on the recent passing of Co-Licensee Roland Zaech. LPA Colvin met with Facility Manager Vanessa Franco and advised her of the purpose of today's visit.

LPA Colvin inquired about the residents at the facility and confirmed that their care has not been disrupted since the passing of Roland Zaech. LPA Colvin found the facility to be in good condition, and the residents gathered in the living room watching television. No health or safety concerns observed at this time. LPA Colvin advised Facility Manager Vanessa to have surviving Licensee Cyndy Zaech to contact the Central Application Branch (CAB) of Community Care Licensing (CCL) and to inquire about what forms need to be updated. CAB can be reach at 833-827-6084.

Additionally, while LPA Colvin was at the facility, LPA Colvin informed Facility Manager Vanessa that the facility has past due fees in the amount of $742.00 for last year's annual licensing fee and subsequent late fee. LPA Colvin will be issuing a Technical Violation today for the past due fees instead of a deficiency due to the recent passing of the Licensee. LPA Colvin also consulted with Facility Manager Vanessa regarding the "No Visitors" sign on the front door. Despite the sign, there is substantial evidence of the facility allowing visitors, as there is a sign in sheet at the front door, which has a long list of entries. LPA Colvin assured Facility Manager that she is confident that the facility is in fact allowing visitors and not violating residents' rights, but recommended that they remove the sign from the door to prevent false impressions. LPA Colvin informed Vanessa that if they so choose, they can instead replace the sign with one that states "No entry without mask".

LPA Colvin conducted an exit interview with Facility Manager Vanessa Franco, and a copy of this report and LIC9102-TV Technical Violation was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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 1