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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600211
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:33:42 PM

Document Has Been Signed on 09/17/2024 02:33 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/
DIRECTOR:		MARIANO, FELINORFACILITY TYPE:
740
ADDRESS:2268 HIGHLANDS ROADTELEPHONE:
(510) 724-3248
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 5CENSUS: 4DATE:
09/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:FELINOR MARIANO, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 9/17/2024 at 9:50am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced pre-licensing for a change of ownership. LPA met with Felinor Mariano, Administrator for Fely-Mar (Administrator Mae Morales-Altobar was not available during visit) and explained the purpose of the visit. The facility has an approved fire safety clearance for five (5) non-ambulatory residents.

While LPA was conducting a unannounced pre-licensing visit, LPA toured the facility and observed the following:
  • At 10:31am knife in the desk drawer located in the living room.
  • At 10:35am a knife on the kitchen counter unattended.
  • At 10:37am unlocked chemicals such as, laundry detergent, bleach and other chemicals, toolbox unlocked with tools located in the garage and the door was propped open.
  • At 10:44am bathroom cabinet under the sink was unlocked with chemicals such as Lysol, cleaning spray and other chemicals.
  • At 10:51am drawer in cover area which had unlocked medication such as B12, multi vitamins and prescription drugs.
  • At 10:57am unlocked tools in file cabinet in covered area.
  • At 10:59am unlocked medication in unlocked caregiver rooms.
  • At 11:00am wood planks, pole, cooking pots, ladders, curtain rods, located in the back yard

continue on LIC 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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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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
VISIT DATE: 09/17/2024
NARRATIVE
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continue from LIC 809
  • At 11:05 shed needs better lock, boxes of shoes, clutters, tools, baskets, sheets, paint bucket, and other debris located on the side yard covered porch
  • Resident files are incomplete.
  • Staff files not available.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2024 02:33 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/17/2024 at 12:47 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: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2024
Section Cited

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(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept... persons other than employees responsible for the ...
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Based on observation, the licensee did not comply with the section cited above. LPA observed unlocked central storage for medications which poses an immediate health risk to persons in care.
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Type A
09/18/2024
Section Cited

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(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Based on observation the licensee did not comply with the section cited above by having a knife in the drawer located in the living room and a unattended knife on the kitchen counter which poses a health and safety risk to persons 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 Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2024 02:33 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/17/2024 at 01:04 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: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2024
Section Cited

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Maintenance and Operation:(a) 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.
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Based on observation, the licensee did not comply with the section cited above in having shed needs better lock, boxes of shoes, clutters, tools, baskets, sheets, paint bucket, and other debris located on the side yard covered porch
, which poses a potential health and safety risk to persons in care.
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Type B
10/01/2024
Section Cited

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
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Based on record review, the licensee did not comply with the section cited above in not having files for the staff on duty which poses a potential health and safety risk to persons 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 Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2024 02:33 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/17/2024 at 02:10 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: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2024
Section Cited

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Resident Records: The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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This requirement is not met as evidenced by: Licensee failed to ensure resident records were maintained. LPA observed resident files were incomplete/not on file: no consent form (CF), (ANS), emergency contact (ID), safeguards for personal property, expired medical assessments LIC 602 and appraisal needs and service plans on file for R1, R2 and R3.
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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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
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