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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600211
Report Date: 12/21/2022
Date Signed: 12/21/2022 12:10:50 PM


Document Has Been Signed on 12/21/2022 12:10 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:FELY-MAR ELDERLY CARE HOMEFACILITY NUMBER:
075600211
ADMINISTRATOR:MARIANO, FELINORFACILITY TYPE:
740
ADDRESS:2268 HIGHLANDS ROADTELEPHONE:
(510) 724-3248
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:5CENSUS: 4DATE:
12/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Felinor Mariano, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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On 12/21/2022 at 8:45AM, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct a POC visit. LPAs met with Felinor Mariano Administrator and explained the purpose of the visit.

Facility has the following deficiency that was not cleared and deficiencies were issued on 11/17/2022 from California Code of Regulations, Title 22:
- 80086 (c); LPA have not received a copy of the permit, updated facility sketch nor an LIC200. POC due date was 12/20/2022 for deficiency.

Civil penalties of $100 per day is assessed for failure to correct 80086(c). Facility is subject to ongoing civil penalties until deficiency is corrected.

LPAs observed the following deficiencies during today's POC visit:

-LPAs observed R1, R2, R3, and R4 did not have doctor's orders for bed rails.
-LPAs observed that resident records for R1, R2, R3, and R4 was not complete.
-LPAs observed tile saw, saw, lawn mower, 2 ladders shovel, 3 propane tanks, 2 tires, horse work bench, air compressor, and other items located on left side of house.

An immediate civil penalty of $250.00 will be assessed on today's date for a repeat violation 87303(a).

Exit interview conducted. A copy of this report, LIC421FC and appeal rights provided
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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 12/21/2022 12:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited

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(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide ... Postural supports may be...(3) A written order from a physician indicating... postural support shall be maintained... require other additional ...This requirement was not met as evidence by:
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Licensee agreed to submit a written doctors order for bedrails for R1, R2, R3 and R4 to CCLD no later then the POC date.
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Based on LPAs observation licensee did not comply with the section cited above by not having a written order for bed rails for R1, R2, R3 and R4 from a physician which poses a potential health and safety risk to residents in care.
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Type B
02/03/2023
Section Cited

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative...
.This requirement was not met as evidence by:
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Licensee agreed to complete residents files and provide self certification that files have been completed to CCLD no later then the POC date.
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Based on LPAs observation licensee did not comply with the section cited above by not having residents records completed which poses a potential health and safety risk to residents in care.
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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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/21/2022 12:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidence by:
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Licensee agreed remove all items from the side yard and provide photos to CCLD no later then the POC date.
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Based on LPAs observation licensee did not comply with tyhe section cited above by having saw, saw, lawn mower, 2 ladders shovel, 3 propane tanks, 2 tires, horse work bench, air compressor, and other items located on left side of house which poses a potential health and safety risk to residents
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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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
LIC809 (FAS) - (06/04)
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