075600211-6-28-2021-15-AS-KHOS-C4PL8J-20210707083202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600211
Report Date: 06/28/2021
Date Signed: 06/28/2021 02:40:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2021 and conducted by Evaluator Allison O'Hollaren

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210616170448

FACILITY NAME:	FELY-MAR ELDERLY CARE HOME		FACILITY NUMBER:	075600211
ADMINISTRATOR:	MARIANO, FELINOR		FACILITY TYPE:	740
ADDRESS:	2268 HIGHLANDS ROAD		TELEPHONE:	(510) 724-3248
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	5	CENSUS: 3	DATE:	06/28/2021
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Felinor Mariano		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility allowing an unauthorized adult to reside on the premises

INVESTIGATION FINDINGS:

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On 06/28/2021 at approximately 9:20am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a 10-day initial complaint opening. LPA met with Licensee Felinor Mariano.

During visit, LPA interviewed Licensee, one staff, and three residents. LPA reviewed staff roster, resident roster, and resident physician reports.

Licensee stated that an adult that does not have fingerprint clearance is living in the storage room and enters the rest of the facility. Licensee stated adult has been living in the facility for one week.

Continued on LIC9099-D...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210616170448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FELY-MAR ELDERLY CARE HOME	FACILITY NUMBER: 075600211
	VISIT DATE: 06/28/2021

NARRATIVE

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The Department has conducted an investigation into the above allegation and based upon observations, records review, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation was found to be SUBSTANTIATED.

Civil penalties assessed in the amount of $500 for unauthorized adult living at the facility without fingerprint clearance.

Type A Deficiency cited per California Code of Regulations, Title 22, and listed on LIC 809D. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.

LIC 809, 809D, Appeal Rights, and LIC 421B provided and exit interview conducted with Licensee.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20210616170448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FELY-MAR ELDERLY CARE HOME	FACILITY NUMBER: 075600211
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/29/2021 Section Cited CCR 87355(b)	1 2 3 4 5 6 7	87355 Criminal Record Clearance (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or	1 2 3 4 5 6 7	Unauthorized adult will leave facility immediately. Licensee will review regulation and submit self-certification by POC date.
	8 9 10 11 12 13 14	exemption. This requirement was not met as evidence by: Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee stated that an adult that does not have fingerprint clearance. This requirement was not met as evidenced by: Licensee stated unauthorized adult has been living in the storage room for a week and enters the rest of the facility without fingerprint clearance which poses an immediate health, safety or personal rights risk to persons 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.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

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