<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202880
Report Date: 02/20/2025
Date Signed: 02/21/2025 08:49:03 AM

Document Has Been Signed on 02/21/2025 08:49 AM - 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: 2DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Marie Pendar, ADMTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On February 20, 2025, at 2:25 PM, Licensing Program Analyst (LPA) Kenneth Madrigal and Mita Partoza conducted an unannounced annual inspection visit, and met with Marie Pendar, Administrator (ADM). Upon arrival, Staff 1 (S1) identified themselves and LPAs were granted access to the facility as LPAs explained the purpose of the visit.

During the entrance of the inspection, LPAs observed 2 residents and 1 staff. LPA toured the facility inside out with ADM which included the living room, kitchen, dining room, two restrooms, two residents’ bedrooms, and four vacant resident bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. Two-day perishable food supplies and seven-day nonperishable food supplies were observed. LPA observed the cleaning product storage area is locked and inaccessible to residents in care. Room temperature was at 68 degrees F, and hot water temperature was measured at 103.1 degrees F in both resident bathrooms.

Based on LPAs observations, food stored in the kitchen freezer has freezer burns, medication storage is not locked which is accessible to residents in care, knives and sharps storage is not locked which is accessible to residents in care, S1 is not associated to the facility, unknown substance stored inside an opened laundry detergent bucket outside in the backyard. ADM stated that there are no chemicals in the bucket. Additionally, an opened soil bag is located outside in the backyard and is easily accessible to residents, floor tiles and two glass windows located outside the backyard is also accessible to residents in care.

Fire extinguisher was last serviced on January 12, 2024. The facility was equipped with smoke and carbon monoxide detectors. In today’s visit, the smoke detectors were not tested by Adm. LPA observed facility first aid kit. LPAs will continue the record review for facility fire/earthquake drill log. The facility's last drill was on January 12, 2024.

PAGE 1 OF 2. SEE LIC809-C.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
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: 02/20/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPAs interviewed S1 and S1 stated he/she started working at the facility on 2/7/2025 which matches the Personnel Record. Based on record review, S1 is not associated with the facility. ADM stated he/she is in the process of associating S1 to the facility. LPAs informed ADM that based on CCR Title 22 87355 (e) (2) prior working, residing, or volunteering in a licensed facility; Request a transfer of a criminal record clearance as specified in Section 87355 (c). Violation of this section shall result in an immediate assessment of civil penalties of one-hundred-dollar ($100) per violation per day for a maximum of five (5) days by the department and a total of $500.

LPAS and ADM informed S1 that they could not be in the facility until the ADM submits the LIC 9182, Criminal Record Clearance Transfer Request Form with required supporting documents to the Department and approved by CDSS.

Deficiencies cited today for 87353 (e) (2) based on LPA observations, interviews conducted and record reviews in accordance with the California Code of Regulations (CCR) Title 22. Based on observations, the following deficiencies will be cited in a future date:
Operational Requirements - 87706(a)(1)(C) S1 has no training record
Physical Plant/Environmental Safety: 87303(e)(3) Water Temperature is not within range.
Physical Plant/Environmental Safety 87309(a)(2) Food storage not with labels
Physical Plant/Environmental Safety 87309(b)(1) Medication and knives are not locked and secured.

The annual inspection will be continued based on observation, record reviews, and findings during today’s visit.

This Evaluation Report was reviewed with Marie Pendar, Administrator. Also, a copy of the signed report and Appeal Rights was provided to ADM.

END OF REPORT. PAGE 2 OF 2.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 02/21/2025 08:49 AM - It Cannot Be Edited


Created By: Kenneth Madrigal On 02/20/2025 at 05:26 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355(e)(2) - 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: (2) Reqest a transfer of a criminal record clearance specified in section 87355(c) This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview. S1 stated that he/she started working on 2/7/2025 at the facility. ADM stated S1 is new and is currently working in associating S1 to the facility. Per record review in Guardian check, S1 has a cleared criminial record. The licensee did not comply with the section cited by not timely associating S1 to the facility prior to having S1 work at the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
1
2
3
4
ADM stated that she will submit the LIC 9182, Criminal Record Clearance Transfer Request Form with required supporting documents to the Department by POC due date. ADM will fax the confirmation of this request.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Jackie Jin
LICENSING EVALUATOR NAME:Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9