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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200737
Report Date: 08/13/2021
Date Signed: 08/13/2021 02:42:57 PM

Document Has Been Signed on 08/13/2021 02:42 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:
08/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Sabrina Balal & Joseph GapasinTIME COMPLETED:
03:00 PM
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On 8/13/2021, Licensing Program Analyst (LPA) Leslie Ibo conducted a Case Management visit with S1 & S2 in relation to the special incident report received on 7/26/2021, S3 missed to give R1’s prescribed medication.

Incident report stated that on 7/25/2021 S3 did not give R1’s medication on time. R1’s physician was informed, per doctor’s instruction, continue medication for the next dose (8:00PM on 7/25/2021). Facility Administrator re-trained S3 & other staffs.

LPA requested for the following documents but not limited to, Medication Administration record for R1, LIC500, residents’ roster and training documentation.


Deficiency was cited from the California Code of Regulations, Title 22.

Exit interview conducted. Appeal Rights and a copy of report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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 08/13/2021 02:42 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/13/2021 at 02:12 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: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care:(c) ...facility staff designated by the licensee shall be permitted to assist the resident with self-administration...(2)Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidence by:
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Adminsitrator will complete in-service medication training for ALL staffs working in the facility, a copy of the training in-service will need to be submitted on before 8/27/2021. Any repeat violation within 12months will result to civil penalty.
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Based on LPA interview and records review: S3 did not give R1's medication on time. This poses a potential threat to the health and safety of clients in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021


LIC809 (FAS) - (06/04)
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