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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201275
Report Date: 11/27/2023
Date Signed: 11/27/2023 04:41:07 PM

Document Has Been Signed on 11/27/2023 04:41 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
OAKLAND ASC, 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: 5DATE:
11/27/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marlesta Manor Administrator Ashley FernandezTIME COMPLETED:
04:45 PM
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On119/27/2023, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a health check as a result of a Priority 1 complaint. Upon entry, LPA stated the purpose of the visit to Administrator Ashley Fernandez.

LPA toured facility, including but not limited to the bedrooms, bathrooms, common area, kitchen and outdoor area. Facility temperature was maintained at 68 degrees F. More than the minimum of 7 days of non-perishable and 2 days of perishable food supplies were on hand. Resident medications were kept locked in the cabinet. Fire extinguisher was full, Smoke and Carbon monoxide detectors tested and were functional. The access to the body of water was locked.

No citations were issued.

Exit interview conducted and a copy of this report provided to Licensees via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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