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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200737
Report Date: 04/19/2022
Date Signed: 04/19/2022 05:43:42 PM

Document Has Been Signed on 04/19/2022 05:43 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:
04/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Joseph Gapasin, LVNTIME COMPLETED:
06:00 PM
NARRATIVE
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On 4/19/22 at approximately 2:55pm, Licensing Program Analysts (LPAs) C. Lin and K. Nguyen arrived an unannounced case management visit regarding the self-report incident report dated on 3/29/22 for medicine error to resident. LPAs met with LVN Joseph Gapasin and explained the purpose of visit.

Based on observation, interview and record review, LPAs observed that resident did miss two doses of medicine on 3/27/22 and 3/28/22, however, resident has no change in health condition because of it. LVN admitted that training has not been provided to staff after the incident occurred.

The deficiencies were observed and indicated in LIC 809D, and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with LVN. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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 04/19/2022 05:43 PM - It Cannot Be Edited


Created By: Catherine Lin On 04/19/2022 at 05:01 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: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2022
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful...
This requirement was not met as evidenced by:
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Administrator and LVN will retrain staff for seven rights medication, and submit proof of training to CCL by the POC due day.
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Based on observation, licensee did not comply with the section cited above. LPAs observed medicine was not reflled timely that resulted resident missed two doses of medicine which poses an immediate health, safety risk to persons in care.
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Type A
04/21/2022
Section Cited
CCR87411(c)(3)(D)

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87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(3) The training shall include, but not be limited to, the following:
(D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection.
This requirement was not met as evidenced by:
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Administrator and LVN will retrain staff for all required sessions on the regulation, and submit training agenda and staff sign-in sheet to CCL by the POC due day.
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Based on observation, interview and record review, licensee did not comply with the section cited above. LPAs observed no training has been provided to staff after incident occurred which poses an immediate health, safety risk to persons 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:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
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