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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600367
Report Date: 11/30/2022
Date Signed: 12/01/2022 02:21:46 PM

Document Has Been Signed on 12/01/2022 02:21 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MARIAN'S CARE HOME IFACILITY NUMBER:
385600367
ADMINISTRATOR:CUA, MARIAN TORRESFACILITY TYPE:
740
ADDRESS:1450 - 24TH AVENUETELEPHONE:
(415) 269-1500
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 6CENSUS: 6DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Marian CuaTIME COMPLETED:
10:45 AM
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On 11/30/22, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was screened at the front entrance. LPA was greeted caregivers, Maritess Dator and Perfectoau (Bok) Eugenio and the Administrator, Marian Cua arrived shortly and assisted with the rest of the inspection. LPA explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, and containment strategies.

Facility appeared to be cleaned and tidy. There are 3 bedrooms upstairs (2 for residents and 1 for staff) and 5 bedrooms downstairs (4 for residents and 1 for staff); all the residents have their own room. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap, closed lid garbage can, and hand washing instruction is posted by the hand washing stations.

Medications are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and completed.

During tour of the kitchen, LPA observed toxin underneath the kitchen sink cabinet and the sharps are not locked.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator.

This report is discussed and reviewed with the Administrator. A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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 12/01/2022 02:21 PM - It Cannot Be Edited


Created By: Murial Han On 11/30/2022 at 10:06 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARIAN'S CARE HOME I
FACILITY NUMBER: 385600367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87309 Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: LPA observed sharps, disinfectants, cleaning solutions not properly locked which poses an immediately health risks to residents in care.
POC Due Date: 12/01/2022
Plan of Correction
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The administrator will provide in-services to staff on the importance of ensuring sharps, disinfectants, cleaning solutions, etc are properly stored and locked at all time. The administrator will submit a plan to ensure compliance by the plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022


LIC809 (FAS) - (06/04)
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