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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201176
Report Date: 12/06/2022
Date Signed: 12/06/2022 10:50:08 AM

Document Has Been Signed on 12/06/2022 10:50 AM - 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:MARSTON CORPORATIONFACILITY NUMBER:
079201176
ADMINISTRATOR:UY, RONALDFACILITY TYPE:
740
ADDRESS:871 BRITTANY LANETELEPHONE:
(650) 255-9603
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 5DATE:
12/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:CYNTHIA DINGLASAN, StaffTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Jill Clancy-Czuleger, conducted an unannounced pre-licensing inspection. License application is for 6 total capacity, of which 5 maybe non-ambulatory and 1 maybe bedridden. Fire clearance was granted on August 22,2022. LPA met with Cynthia Dinglasan administrator.

LPA inspected the facility inside and out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade.

Fire extinguishers were observed fully charge and tags showed serviced February 22, 2022. The two-in-one carbon monoxide and smoke detector tested and observed functional. First aid kit checked and observed complete with manual. Hot water temperature in one of the bathrooms tested and measured at 110.4 degrees Fahrenheit.

LPA observed Personal Protective Equipment (PPE) for residents, staff and visitors and a PPE station to monitor and record all incoming visitors.

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SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MARSTON CORPORATION
FACILITY NUMBER: 079201176
VISIT DATE: 12/06/2022
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Continued from 809...

Comp III was discussed with Applicant.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and a copy of this report will be given.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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