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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803231
Report Date: 01/24/2023
Date Signed: 01/24/2023 12:14:27 PM

Document Has Been Signed on 01/24/2023 12:14 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MARIAN HOUSE FOR SENIORSFACILITY NUMBER:
496803231
ADMINISTRATOR:SUMABAT, RAMON & SHEILAFACILITY TYPE:
740
ADDRESS:2043 GUERNEVILLE ROADTELEPHONE:
(707) 843-7087
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rosie Chacon-Lead CaregiverTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Alviso, conducted a Required 1 -Year Inspection, 1/24/23 at approximately 10:00am, and met with Lead caregiver Rosie(Rosario) Chacon & Fely Delapena. LPA observed two)2) staff on duty. The inspection is focused on the Infection Control procedures and practices of this facility. Staff, pm shift, Silver Berie Fernandez, was sleeping in the staff room.

The facility has submitted to the Department, the required Infection Control Plan Facility has an approved dementia plan of operation. There is an approved hospice waiver for four (4) residents. Fire clearance is approved for six (6) non-ambulatory. Fire extinguisher was serviced and tagged as required, expires 8/3/2023.
There were six(6) residents in care, one(1) on hospice services. Facility does screen visitors and residents as needed. Temperatures are taken, and screening questions are asked, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature. All exits were free from obstruction. All smoke alarms, nine(9), were found to be working appropriately during the inspection. Toxins/cleaners are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored and locked in cabinets, making them inaccessible to residents in care. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. LPA discussed with staff to keep postings updated as needed. Facility has a sufficient supply of personal protective equipment(PPE) for staff, and visitors use. Residents have masks/PPE available to them for their use if needed and/or wanted. Staff, two(2), were observed by the LPA to be wearing masks upon LPA's arrival, and during the inspection.
No deficiencies found in the areas inspected. No citations issued.
Exit interview conducted with Rosario Chacon-Lead Caregiver.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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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