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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201176
Report Date: 09/15/2023
Date Signed: 09/15/2023 04:10:57 PM

Document Has Been Signed on 09/15/2023 04:10 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:MARSTON CORPORATIONFACILITY NUMBER:
079201176
ADMINISTRATOR:UY, RONALDFACILITY TYPE:
740
ADDRESS:871 BRITTANY LANETELEPHONE:
(650) 255-9603
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: DATE:
09/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Kristabelle Alatas, Corperate board member TIME COMPLETED:
04:20 PM
NARRATIVE
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On 05/07/2021, Licensing Program Analysts (LPA) J. Clancy-Czuleger and Alona Gomez conducted a Case Management with in relation to the Special incident report submitted on 09/06/2023.

During interview and record review it was determined that medication was given to R1 that was intended for R2. The facility w

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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 09/15/2023 04:10 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 09/15/2023 at 03:28 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: MARSTON CORPORATION
FACILITY NUMBER: 079201176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2023
Section Cited
CCR
87465(c)(2)

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If the resident's physician has stated in writing that the resident is unable to determine ... facility staff designated by the licensee shall be permitted to assist the resident ...Once ordered by the physician the medication is given according to the physician's directions.
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The facility will conduct an all staff training relating to medications and how to dispense it. Proof of correction will be sent to CCLD by POC date.
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requirement is not met as evidenced by: The staff gave the resident the wrong medication
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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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023


LIC809 (FAS) - (06/04)
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