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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200737
Report Date: 04/23/2021
Date Signed: 04/23/2021 12:47:20 PM

Document Has Been Signed on 04/23/2021 12:47 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CALIFORNIA MENTOR-MARINEVIEW HOMEFACILITY NUMBER:
019200737
ADMINISTRATOR:JOE FARRISHFACILITY TYPE:
740
ADDRESS:2420 MARINEVIEW DRIVETELEPHONE:
(916) 300-9510
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 4CENSUS: 4DATE:
04/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Joe FarrishTIME COMPLETED:
12:45 PM
NARRATIVE
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On 04/23/2021 Licensing Program Analyst (LPA) Allison O'Hollaren conducted an unannounced case management visit regarding a self reported incident. Due to the Shelter in Place set forth by the Governor on March 17, 2020, LPA was not able to conduct the visit in person. The visit was performed by telephone. LPA spoke with Administrator, Joe Farrish.

During the phone call LPA spoke and reviewed incident with Administrator. Administrator confirmed that R1 was not given a dosage of medication on 04/05/2021. The error was discovered the following day on 04/06/2021.

The following deficiency was cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report emailed.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2021
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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Document Has Been Signed on 04/23/2021 12:47 PM - It Cannot Be Edited


Created By: Allison O'Hollaren On 04/23/2021 at 12:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA MENTOR-MARINEVIEW HOME
FACILITY NUMBER: 019200737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2021
Section Cited
CCR
87465(c)(2)

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87465 (c) If the resident's physician has stated in writing... facility staff designated ... provided all of the following requirements are met: (2) Once ordered...the medication is given according to the physician's
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Administrator agrees to conduct an in-service training with staff and fax a copy of the agenda with signatures to CCLD by POC date.
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directions. This requirement was not met as evidenced by: Based on LPA interview staff did not comply with the regulaton stated above which poses a potential health and safety risk to the resident.
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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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2021


LIC809 (FAS) - (06/04)
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