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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202880
Report Date: 07/24/2024
Date Signed: 07/24/2024 12:38:38 PM

Document Has Been Signed on 07/24/2024 12:38 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/
DIRECTOR:		PENDAR, MARIEFACILITY TYPE:
740
ADDRESS:373 BAY STTELEPHONE:
(480) 578-6785
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 3DATE:
07/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Marie Pendar TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 7/24/2024, Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcela Yanez, conducted an case management - deficiencies during a complaint investigation and discussed the case management deficiencies with administrator (ADM) Marie Pendar.

Based on record review and interview, ADM did submit the necessary documents to associate and clear staff (S1) that was previously cited on 2/4//2024. The documents submitted has typographical errors and was not processed by Guardian.

Based on interview with ADM, emails were sent but no follow up after the emails. Based on documentation, LPA Monter follow-up with ADM on 2/26/2024, informing ADM that there was error on the information of S1.

Based on document review, S1s information was corrected, but the facility number was missing a number. The livescan for S1 was processed but has the wrong facility license number and Guardian was not able to process due to non-follow up from ADM. ADM was able to clear the matter of typographical error with Guardian, and was provided a PIN to process the application and associate S1.

Based on interview ADM stated he/she did not receive a notification from Guardian regarding S1. ADM stated he/she is not familiar with Guardian and did not know how to access the website. Based on interview, ADM did not follow up with Guardian for S1s livescan and association.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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
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: 07/24/2024
NARRATIVE
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LPAs requested a copy of request for live scan, copy of DOJ response, LIC 9182 and a copy of S1s identification and a note to Guardian with PIN for S1.

Deficiency is cited during today's visit based on California Code of Regulation (CCR) Title 22. See LIC 809D. An exit interview was conducted with administrator Marie Pendar and a copy of the report and appeals rights were provided.

87405 - Administrator Qualification (d) The administrator shall have the qualification as specified in Section 87405(d)(1) through (7). (2) Knowledge of and the ability to conform to the applicable laws, rules and regulations.


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end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2024 12:38 PM - It Cannot Be Edited


Created By: Maria Partoza On 07/24/2024 at 12:15 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: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2024
Section Cited
CCR
87405(a)(1)-(7)(2)

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87405 - Administrator Qualification (d) The administrator shall have the qualification as specified in Section 87405(d)(1) through (7). (2) Knowledge of and the ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by.
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ADM stated that she will follow up with Guardian until she get the confirmation and will email LPA proof of correction and confirmation that the confusion has been resolved.
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Based on interview, ADM did not exhibit understanding of the applicable laws, rules and regulations by assuming that S1s livescan automatically will be associated with the facility.
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
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