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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200737
Report Date: 10/07/2024
Date Signed: 10/07/2024 12:51:07 PM

Document Has Been Signed on 10/07/2024 12:51 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:		JOSEPH GAPASINFACILITY TYPE:
740
ADDRESS:2420 MARINEVIEW DRIVETELEPHONE:
(510) 957-5612
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 4CENSUS: 3DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Area Director Rosemary MaurilioTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 10/07/2024 at 08:30 AM, Licensing Program Analysts (LPAs) David Doidge and James Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Nena Gibson Program Supervisor and Area Director Rosemary Maurilio arrived at 10:00 AM.

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Smoke detectors and carbon monoxide detectors were fully functional. Fire extinguishers were observed to be full and last serviced on 08/28/2024. Temperature in the facility was measured at 72.0 degrees Fahrenheit at 08:53 AM and facility cited for hot water measured at 127.7 degrees Fahrenheit at 8:53 AM.

The LPAs observed required postings in the facility, including the Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy.

Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction.

One week of nonperishable and 2 days of perishable food supplies were available.

1 A-Type citation issued and 1 B-Type citation issued.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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 3
Document Has Been Signed on 10/07/2024 12:51 PM - It Cannot Be Edited


Created By: David Doidge On 10/07/2024 at 11:52 AM
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: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 as water temperature observed at 127.7 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2024
Plan of Correction
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Bring water temperature to between 105 and 120 degrees Fahrenheit and submit proof to LPA D. Doidge
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:David Doidge
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/07/2024 12:51 PM - It Cannot Be Edited


Created By: David Doidge On 10/07/2024 at 11:52 AM
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: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

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 as gate does not self close, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Install self closing mechanism for exterior gate and submit proof to LPA D. Doidge
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:David Doidge
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


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