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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600211
Report Date: 10/08/2024
Date Signed: 10/08/2024 11:56:04 AM


Document Has Been Signed on 10/08/2024 11:56 AM - 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:
10/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mae Morales-Altobar AdministratorTIME COMPLETED:
12:00 PM
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On 10/8/2024 at 09:45 AM, Licensing Program Analysts (LPAS) Carol Fowler and David Doidge arrived unannounced to conduct a POC (proof of correction) inspection. LPAs met with Mae Morales-Altobar Administrator informed her the reason for the visit.

The following deficiencies were cleared by visit:

- 87465(h)(2); during inspection medications removed. Care givers bedroom doors will be locked at all times.
- 87412(a) Administrator updated employee records to include all required documents.
- 87506(a) Administrator updated resident records to include all required documents
- 87705(f)(1) Staff has locked up all sharps. Administrator will ensure sharps will remain locked at all times.
- 87303(a); Administrator removed items from porch on side yard, and will ensure area remains clear.

exit interview conducted and copy of this report provided..

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
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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