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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202880
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:32:38 PM

Document Has Been Signed on 02/02/2024 03:32 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
CENTRAL COAST CR/RES, 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: 2DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Marie PendarTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Manuel Monter and Mita Partoza conducted an unannounced annual inspection visit, and met with Administrator (ADM) Marie Pendar. During the visit, LPA observed 2 residents and 1 staff.

As LPA's attempted to enter the facility, LPA's observed a locked gate. LPA's rang the button near the black metal door and staff exited the front door and unlocked the metal gate with a key. The metal gate has a dead bolt lock on both sides, requiring a key to open. (Photographs taken.)

LPA's asked staff S1 his/her name. LPA's cross referenced residents name with LIS personnel and guardian. S1 is not associated to the facility. S1 stated he/she has been working at the facility since October 2023. ADM stated S1 is not associated at this facility.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms. While touring facility bathroom #2, LPA's observed a spray bottle of Lysol. (Photographs taken.) LPA's toured 6 residents bedrooms. While touring resident bedroom #2, LPA's observed dead flies and cobwebs at the window sill. (Photographs taken.) . The staff area of the facility was also inspected. The front yard and backyard were inspected. While touring the backyard, LPA's observed a mallet, outside of the garage door to the backyard. LPA's also observed a lawn mower and a red container, with gasoline inside, located between the garage door exit to the back yard and the kitchen window. (Photographs taken. ) While touring the backyard, LPA's observed Miracle-Gro plant food and Insect & Fungal disease control spay was observed in the backyard, near resident bedroom #1. LPA's observed a mini electric stove, next to the outlet in the back yard, near resident bedroom #1. (Photographs taken)
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 02/02/2024 03:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/02/2024 at 02:22 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARCEL'S MEMORY CARE
FACILITY NUMBER: 435202880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's measurement, the licensee did not comply with the section cited above. Facility kitchen water tempreture was measured at 142 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated she will adjust facility water temperature to within acceptable levels and provide proof of correction by POC due date. Facility to maintain water temperature maintenance log for 1 week and provide report to licensing upon completion.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA's observed in the front gate of the home, a locked gate. The metal gate has dead bolt lock on both sides, requiring a key to open. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated she will remove the dead bolt lock. ADM stated she will send photo documentation the lock has been removed. ADM stated she will send documentation by POC date, 02/03/2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 02/02/2024 03:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/02/2024 at 02:22 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARCEL'S MEMORY CARE
FACILITY NUMBER: 435202880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)
Adminstrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. ADM did associate S1 who has been working since October 2023. R1's MAR states R1 refused in future dates. ADM stated she locked the front gate to the facility due to residents wandering behaviors. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated she will send letter of understanding regarding the regulation. ADM stated she will send letter by POC date 2/3/2024.
Type A
Section Cited
CCR
87207
87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. While reviewing R1's MAR, the form states R1 refused Medication #1 from Feburary 1st to Feburary 8, 2024. Today is Feburary 2, 2024. ADM stated that was a mistake. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated she will send plan of action on how the facility will ensure resident medications are accurate, to ensure false informaton isn't disseminated. ADM stated she will send plan of action by POC date, 02/03/2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/02/2024 03:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/02/2024 at 02:22 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARCEL'S MEMORY CARE
FACILITY NUMBER: 435202880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed in resident bedroom #2's window sill dead flys and cobwebs. LPA observed a red container with gasoline in the backyard, located in between the garage door and kitchen window. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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ADM stated she will send plan of action on how she will ensure the facility is clean and safe. ADM stated she will send plan of action by POC date, 02/09/2024.
Type B
Section Cited
CCR
87309(a)
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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a spray bottle of Lysol. in bathroom #2's cabinete, below the sink. LPA observed Miracle-Gro plant food and Insect & Fungal disease control spay was observed in the backyard, acessible to residents in care. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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ADM stated she will send plan of action on how the facility will ensure disinfectants, cleaning solutions and other items which could pose a danger to residents are stored in a secure place, inacessible to residents in care. ADM stated she will send plan of action by POC date, 02/09/2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/02/2024 03:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/02/2024 at 02:22 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARCEL'S MEMORY CARE
FACILITY NUMBER: 435202880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. ADM stated she has not yet updated the staff files for herself or S1. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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ADM stated she will send plan of action on how the facility will ensure that personnel records are maintained on the licensee, administrator and each employee, for the facility. ADM stated she will send plan of action by POC date, 02/09/2024.
Type B
Section Cited
CCR
87355(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LPA reviewed S1's name in gaurdian, and S1 is not associated with the facility. ADM stated she has not associated S1 to the facility. ADM stated S1 has been working at the facility since October 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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ADM stated she will associate S1. ADM stated she will send letter of understanding regarding the regulation. ADM stated she will send the letter by POC date, 02/09/2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 02/02/2024 03:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/02/2024 at 02:22 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARCEL'S MEMORY CARE
FACILITY NUMBER: 435202880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. While auditing R1's medications, LPA's observed two loose medication tablets sitting in the bottom of the medication plastic container, which holds the medication bottles. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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ADM stated she will send plan of action on how the facility will ensure medications are stored in its orginal container. ADM stated she will send plan of action by POC date, 02/09/2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. ADM stated she has not conducted a drill. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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ADM stated she will conduct a drill and send documentation to LPA that a drill has taken place. ADM stated she will send by POC date, 02/09/2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


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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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MARCEL'S MEMORY CARE
FACILITY NUMBER: 435202880
VISIT DATE: 02/02/2024
NARRATIVE
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Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 108 degrees F in both resident bathrooms. LPA measured facility kitchen sink water temperature, at 142 degrees F.

Fire extinguisher was serviced in January 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit. LPA requested to review facility drill log. ADM stated she has not conducted a drill yet.

LPA reviewed facility records for 2 residents. LPA reviewed 2 resident medications and centrally stored medication records and Medication Administration Record (MAR). While review R1's medication records LPA's observed 2 medication tablets, unsecured in the bottom of the medication container. While reviewing R1's medication records, Medication #1 and Medication #2 was not listed on the Centrally Stored Medication Log. While reviewing facility MAR for R1, LPA's observed the MAR states R1 refused Medication #1 from February 1st to February 8, 2024. ADM stated that was a mistake.

LPA requested to review 2 staff records. ADM stated the files were not available. ADM went to get the staff files, which were located at her other facility, at 1:30pm. ADM returned at approximately 1:50pm. LPA reviewed Staff S1 documents. ADM stated she has not updated staff records of S1 and ADM for Marcel's Memory Care. LPA conducted interviews with 1 staff (S1) and 2 residents (R1-R2).

Deficiencies cited during today's visit. This report was reviewed with Administrator Marie Pendar and a copy of the signed report was provided. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S1 working and residing in the facility without association. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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