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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600754
Report Date: 07/15/2021
Date Signed: 07/21/2021 03:26:30 PM

Document Has Been Signed on 07/21/2021 03:26 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MONTEVERDE MANOR IIIFACILITY NUMBER:
415600754
ADMINISTRATOR:MARTIN, DINO MICHAEL A.FACILITY TYPE:
740
ADDRESS:2650 EDISON STREETTELEPHONE:
(650) 376-3053
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 5DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Dino MartinTIME COMPLETED:
12:15 PM
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On 7/15/2021, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by caregiver, Regidor Gimena. LPA explained the purpose of the visit and LPA was properly screened at the front entrance. .

The Administrator, Dino Martin arrived shortly and assisted with the rest of the inspection.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures (LPA recommended to establish a visitor screening log for record keeping), staff training and policies, resident monitoring, containment strategies, PPE supply is adequate but not all stored in one location, LPA recommended to have PPE supplies store in one location, environmental preparation and cleaning. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. Hand washing stations were equipped with paper supplies and soaps and hand wash signs are posted. First-aid kit is inspected and complete. There are 5 residents present, and 2 staff. All the rooms are private.

No deficiency cited today. This report is reviewed and discussed with the caregiver, Regidor Gimena and a copy is provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2021
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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