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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201275
Report Date: 09/26/2023
Date Signed: 09/26/2023 06:03:53 PM

Document Has Been Signed on 09/26/2023 06:03 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:MARLESTA MANORFACILITY NUMBER:
079201275
ADMINISTRATOR:FERNANDEZ, ASHLEYFACILITY TYPE:
735
ADDRESS:982 MARLESTA RD.TELEPHONE:
(415) 939-4491
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 6CENSUS: 6DATE:
09/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Alexis Fisher, CaregiverTIME COMPLETED:
05:00 PM
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On 09/26/2023 at 02:45AM, Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing inspection (facility is in operation and changing ownership). LPA met with Alexis Fisher, caregiver. Administrator, Monique Hatcher arrived at 3:15pm. The facility has an approved fire safety clearance for six (6) ambulatory clients. During inspection LPA observed three (3) clients and three (3) staff. The other three (3) clients arrived from the day program.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, back yard. The facility has a total of four (4) bedrooms and two (2) bathrooms. LPA observed pool in locked room. There is sufficient lighting around the facility. Clients rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with non skid mats. Passageways and hallways are free of obstruction. Locked cabinets available to store medications, toxins and sharps. Hot water temperature is measured at 110.9 degrees Fahrenheit. Fire extinguisher was last serviced on 07/02023. There is a minimum of 7-day non-perishables and 2-day perishables foods. First Aid kit was complete. Carbon monoxide and smoke detectors present.

Prior to licensure, the following shall be corrected and faxed to CCL by 10/03/2023.
  • Facility will submit an exception to retain individuals age 60 and over to the Centralized Application Bureau analyst.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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: MARLESTA MANOR
FACILITY NUMBER: 079201275
VISIT DATE: 09/26/2023
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Continued from LIC809.

Issues were noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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