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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424970
Report Date: 04/06/2022
Date Signed: 04/06/2022 02:43:03 PM

Document Has Been Signed on 04/06/2022 02:43 PM - 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:
04/06/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Manager Vannassa FrancoTIME COMPLETED:
02:55 PM
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On the above date Licensing Program Analysts (LPA's) Crystal Colvin and Venus Mixson made an unannounced case management visit and were greeted and granted entry by Manager Vanessa Franco.

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. LPA Colvin requested for facility manager to have the licensee submit the following documents to Community Care Licensing:
- Break down of the shares of the corporation.
- List of active officers in the corporation.
- LIC 200 Facility scheduled roster for staff.
- LIC 308
- LIC 309
- Updated lease agreement.
- Death Certificate or other proof of passing Roland Zaech.

LPA's informed Manager Vanessa Franco that these documents would need to be submitted by 4/20/2022.If required documents are not received by this date, an office meeting may be required to discuss facility compliance.

No health or safety concerns observed at this time. Exit interview was conducted and this report was left with Vanessa Franco.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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