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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202880
Report Date: 12/21/2022
Date Signed: 12/21/2022 02:02:23 PM

Document Has Been Signed on 12/21/2022 02:02 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MARCEL'S MEMORY CAREFACILITY NUMBER:
435202880
ADMINISTRATOR:PENDAR, MARIEFACILITY TYPE:
740
ADDRESS:373 BAY STTELEPHONE:
(480) 578-6785
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 0DATE:
12/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:MARIE PENDARTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Steve Chang conducted a pre licensing inspection visit, and met with administrator (ADM) Marie Pendar. LPA did not see the address number plate for the house, ADM stated ADM will pui it on within 7 days. COVID posters and screening station were not observed in the facility, ADM stated ADM will put it on at facility within 7 days. PPE supplies were observed not sufficient for 30 days, ADM stated ADM will put sufficient PPE supplies in facility within 7 days.

LPA toured the facility inside out with ADM. LPA inspected living room, kitchen, dinning area, garage and laundry room. Medication closet, knives closet were observed locked. Cleaning product closet in kitchen was observed not locked, ADM stated ADM will fix it within 7 days. There are 6 single rooms for residents, one office, and one staff live-in room in facility. 2 bathrooms were inspected. Non-skid mats and grab bars were observed in bathrooms. There were no posters of washing hands for 20 seconds by the sinks in kitchen and restrooms, ADM stated ADM will put the posters and paper towels with holders in the kitchen and restrooms within 7 days. Room temperature was observed at 72 degree F, and hot water temperature was observed at 116 degree F.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the smoke and carbon monoxide detectors, and they were working fine. ADM stated the fire extinguishers were bought a month ago, ADM stated ADM will put the receipt on within 7 days. LPA inspected the backyard, there was no obstruction to block the walkway.

ADM stated all staff are fully vaccinated and done with booster shots. ADM stated ADM already submitted the Infection Control Plan. Component III orientation was conducted with ADM.

No citation noted during inspection. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
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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