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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600754
Report Date: 04/29/2026
Date Signed: 04/29/2026 02:16:15 PM

Document Has Been Signed on 04/29/2026 02:16 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MONTEVERDE MANOR IIIFACILITY NUMBER:
415600754
ADMINISTRATOR/
DIRECTOR:		MARTIN, DINO MICHAEL A.FACILITY TYPE:
740
ADDRESS:2650 EDISON STREETTELEPHONE:
(650) 376-3053
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 4DATE:
04/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Caregiver - KimIvanWilfred BudyTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 04/29/2026, 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 2 residents present and 2 caregivers. At 11pm the administrator/licensee arrived and met with LPA. Licensee left facility around 12 noon for an appointment at another location.

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 108F near room 6. Additional bathroom water temperature is measured at 110F 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 with inspection dates of 10/08/2025. All are charged and ready for use. Facility conducts emergency drill quarterly per records reviewed.

Continued on next page...
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MONTEVERDE MANOR III
FACILITY NUMBER: 415600754
VISIT DATE: 04/29/2026
NARRATIVE
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LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Linen closet is observed in the hallway adjacent to Room 1. They are observed as in place for residents. Medications are current, locked, and logged appropriately. First aid kit is present and is filled with the required items. There are two full 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 observed that the facility refrigerator in the kitchen is not fully functioning and does not maintain a cold temperature. LPA measured the temperature at 76F to 77F. LPA also observed unlocked medications in the refrigerator as well in the refrigerator door.

LPA reviewed 3 staff files on this day of which they are current. Staff training records are observed to be current and in place. Resident files are reviewed. 1 of 4 have half rail orders on file. 1 of 4 residents also has full bed rails with no order or exception in place. 1 of 4 residents have current appraisal needs and service plans on file. Administrator certificate for Dino Martin is observed as expired on 12/8/2024. There is a secondary administrator certificate for Mary Grace Juinio with an expiration date of 06/22/2025. LPA informed facility that annuals fees are overdue as of today's visit.

The following updated items are to be received by 05/06/2026:
• Updated copies administrator certificate
• Copy of facility's liability insurance
• LIC500 Staff Schedule


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 LIC809D pages.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/29/2026 02:16 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/29/2026 at 12:29 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MONTEVERDE MANOR III
FACILITY NUMBER: 415600754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(a)
All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the administrator/licensee, Dino Martin, does not have an active or pending administrator certificate at this time. Certifiate is posted in facility expired as of 12/18/2024. This poses and immediate health and safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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Facility shall provide a wrtitten plan adressing this regulation and evidence of enrollment in obtaining his current administrator certificateshall be submitted to the Department.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2026 02:16 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/29/2026 at 12:39 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MONTEVERDE MANOR III
FACILITY NUMBER: 415600754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)2)
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made to the refrigerator, LPA observed several medications unlocked in the refrigerator. The refrigerator itself did not have a lock on the doors and the medications inside were unlocked and accessible to resients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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The licensee shall address this regulation in writing to ensure this regulation is met at all times and the plan of action to be taken to correct this. Included in the plan photos of correction shall be submitted.
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of resident food supplies, LPA discoverd that the main refrigerator in the kitchen does not maitain a cold temperature so there are no food items stored in this location, but is now stored in the garage. LPA measured the temp at 77F in the refrigerator. LPA also found stored medications in the refrigerator as well, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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Licensee shall address this regulation in writing to ensure this regulation is met at all times and the plan of action to be taken to correct this. If repair or replacement is required, the Department shall receive the invoice of such service or replacement as evidence of correction.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2026 02:16 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/29/2026 at 01:14 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MONTEVERDE MANOR III
FACILITY NUMBER: 415600754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)
87467 Resident Participation in Decisionmaking: (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on resident records reviewed, only 1 of 4 residents, currently have an appraisal needs and service plan (LIC625) on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2026
Plan of Correction
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Licensee shall address this regulation in writing in ensuring this regualtion is met at all times. Plan of action is to be received indicating correction and completion of all appraisal needs and service plans being completed and submitted to the Department as proof for the 3 residents who do not have one.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2026 02:16 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/29/2026 at 01:43 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MONTEVERDE MANOR III
FACILITY NUMBER: 415600754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports: (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on resident records reviewed, 1 of 4 residents only have a written order on file indicating the use of a 1/2 bedrail, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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Licensee shall address this regulation in writing ensuring this regulation is met at all times. Plan of action is to be received indicating correction and receipt of doctors orders indicating the use of 1/2 bedrails for the remaining 3 residents.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports: (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obseravations made and records reviewed, 1 of 1 resident is observed to have full bedrails on his/her bed and is not under hospice care. This is considered as prohibited per regulations and poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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Licensee shall address this regulation in writing ensuring this regulation is met at all times. Plan of action is to be received addressing how this resident will be able to continue their resdience in the facility and or actions the faciltiy is going to take to correct this deficiency.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2026


LIC809 (FAS) - (06/04)
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