Monteverde Manor III

Type of visit: POC

On 05/04/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced plan of correction (POC) visit. LPA met with caregiver KimIvanWilfred Budy and explained the purpose of today's visit. During today's visit LPA observed the refrigerator in the kitchen and the medication's that were stored in the refrigerator. LPA observed that the refrigerator in the kitchen is still not working properly, only the freezer. The medications that were previously stored in the refrigerator were removed and moved to an operational refrigerator in the garage and is now in a lock box. According to staff, the licensee/administrator has purchased a new refrigerator but it has not yet been delivered. LPA observed the proof of purchase of a new refrigerator made on 05/04/2026 with a scheduled delivery date of 05/07/2026 per invoice. LPA Vado is clearing the following citations on this day: Incidental Medical and Dental Care 87465(h)(2) - The following requirements shall apply to medications which are centrally stored: 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. - CLEARED 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. - CLEARED No additional citations are issued on this day. Future civil penalties and additional citations may be issued on later dates. This report is reviewed with caregiver KimIvanWilfred Budy and a copy is provided today.the state’s words, verbatim · CDSS document, May 4, 2026

Type of visit: Required - 1 Year

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... Page 2 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.the state’s words, verbatim · CDSS document, Apr 29, 2026

Allegation investigated: - Staff use the facility garage as a living unit

On 10/15/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit. LPA met with caregiver KimIvanWilfred Budy and explained the purpose of today's visit. According to the caregiver, all residents are present in the facility and there 3 staff present but 2 are on duty. During today's visit, LPA toured the facility, observed the garage, and interviewed residents. LPA toured the facility and observed that there is a staff room on the way to the garage. LPA observed a bunk bed and staff belongings in this room. LPA observed the garage, which is accessible to this room via another door, and there are no indications of a bed or living furniture in the garage. The garage houses the laundry machine, dryer, refrigerator, and storage for facility supplies and other miscellaneous items. Based on the observations made, this allegations is unfounded. This agency has investigated the complaint alleging, "Staff use the facility garage as a living unit". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Report is reviewed with KimIvanWilfred Budy and a copy is provided on this day. Unfoundedthe state’s words, verbatim · CDSS document, Oct 15, 2025 · control 14-AS-20251006102504

Type of visit: Required - 1 Year

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... 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)the state’s words, verbatim · CDSS document, May 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: May 7, 2025

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This regulation has not been met as evidenced by: Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bathroom faucets which delivered hot water at 135 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Facility shall submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date of 05/07/2025. Civil penalty assessed on this day as this is a repeat violation within a 1 year period. Civil penalty of $250 assessed

From the deficiency page — Deficiency type: Type A · Section cited: CCR87608(a)(5) · Plan of correction due date: May 7, 2025

POSTURAL SUPPORTS 87608(a)(5) - 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 regulation has not been met as evidenced by: Based on observations made, residents number R1, R2, and R4 have full bed rails. Licensee failed to prohibit use of full bed rails, which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Facility shall submit photo proof of ALL full bed rails removed from resident beds to be removed or reduced to half size. Proof of correction to be submitting to licensing office by due date of 05/07/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: May 13, 2025

POSTURAL SUPPORTS 87608(a)(3) - A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement has not met as evidenced by: Based on observations made, R3 is observed to have hafl bed rails in place but there is no order on file for the resident to have the bed rails in place. Those poses a potential health and safety risk.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Facility shall submit written orders for all residents with half bed rails in place or remove them completely. Proof of correction to be submitting to licensing office on or before the due date of 05/13/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: May 13, 2025

87458(a) Medical Assessment - (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This regulation has not been met as evidenced by: Based on resident files reviewed, R3 does not have a physicians report on file.This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Facility shall ensure that ALL residents shall have either a current physicians report on file or assessments. Incoming residents shall have physicians reports on file at time of admission. Proof of correction to be submitting to licensing office on or before the due date of 05/13/2025.

Type of visit: Case Management - Annual Continuation

On June 19, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility 8:22 AM to complete the Annual Inspection. LPA Calandra was greeted by Albert Pera, Caregiver and explained the purpose of the visit. Dino Martin, Administrator/Licensee arrived later during the visit. LPA Calandra observed one client in the dining room eating breakfast and 2 staff members. LPA Calandra interviewed 2 residents and 2 staff. During the visit, LPA Calandra reviewed client medications. A review of Centrally stored medications indicated that medications for most residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility. The name of one resident, R1's medication was not recorded in the Centrally Stored Medications Records. A Type B violation was provided for not recording all residents medications in the Centrally Stored Medications Records. Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted. This report was reviewed with Albert Pera, Caretaker and a copy of the report along with appeal rights left at the facility.the state’s words, verbatim · CDSS document, Jun 19, 2024

Type of visit: Required - 1 Year

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. This report was reviewed with Dave Enero, Caregiver. A copy of the report along with appeal rights was left at the facility.the state’s words, verbatim · CDSS document, May 24, 2024