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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200737
Report Date: 05/20/2026
Date Signed: 05/20/2026 03:58:01 PM

Document Has Been Signed on 05/20/2026 03:58 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CALIFORNIA MENTOR-MARINEVIEW HOMEFACILITY NUMBER:
019200737
ADMINISTRATOR/
DIRECTOR:		HARLAN, MAEHELLENAFACILITY TYPE:
740
ADDRESS:2420 MARINEVIEW DRIVETELEPHONE:
(510) 957-5612
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 4CENSUS: 4DATE:
05/20/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Precious Yepez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 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 5/20/2026 at 1:00 pm, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 5/14/2026. LPA met with Tahmeya Stover, Program Supervisor and explained the purpose of the visit. Tahmeya phoned Precious Yepez, Administrator (ADM) and the ADM arrived shortly after.

LPA received a self-reported incident report from the facility that indicated that on 5/13/2025, at around 9:30 pm, Resident 1 (R1) eloped from the facility. Interview with staff (S1), S2 and S3 revealed that R1 eloped by exiting through the back gate of the facility. Interview with S2 revealed that S3 offered R1 an alternative beverage and R1 got frustrated and began hitting their room door and cursing at staff. S2 and S3 stated that they were able to calm R1 down and R1 went to sit on the couch in the living room. S2 and S3 stated that R1 got up from the couch and walked towards the backyard and went outside.

S2 stated that they tried to redirect R1 to come back inside but R1 grabbed a stick and aimed it at staff in an aggressive manner. S2 stated that R1 then ran towards the gate to exit the facility. S3 stated that S2 came to tell them that R1 had ran out of the facility but by the time staff went to look outside for R1, R1 had left the facility unassisted. S3 stated that they contacted the police. S2 stated that they drove around the neighborhood but could not find R1 so they returned back to the facility. S1 and S2 stated that R1 returned to the facility around 9:50 pm. S1 and S2 stated that after the incident occurred, staff completed a full body check on R1 and found no injuries.

Continue on LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2026
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CALIFORNIA MENTOR-MARINEVIEW HOME
FACILITY NUMBER: 019200737
VISIT DATE: 05/20/2026
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
Continued from LIC809.

During record review, LPA observed R1's physician report dated 04/22/2026 indicates that R1 is unable to leave the facility unsupervised. LPA observed R1's Individual Behavioral Support plan dated 3/13/2026 indicates that staff are too maintain vigilant supervision of R1 while in the common areas of the facility, particularly when R1 is near exits.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty.

Exit interview conducted with Precious. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/20/2026 03:58 PM - It Cannot Be Edited


Created By: Yasamin Brown On 05/20/2026 at 03:30 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA MENTOR-MARINEVIEW HOME
FACILITY NUMBER: 019200737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2026
Section Cited
CCR
87468.2(a)(4)

1
2
3
4
5
6
7
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision..
This requirement was not met as evidence by:
1
2
3
4
5
6
7
By POC date, The Administrator agrees to review resident's physician's report, creating a plan on increasing safety checks with residents with elopement or wandering, and conducting an in-service training with staff regarding supervision and elopement and send a copy of the training to CCLD.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above by R1 leaving the facility unassisted which posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4