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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201275
Report Date: 08/20/2024
Date Signed: 08/20/2024 06:10:18 PM

Document Has Been Signed on 08/20/2024 06:10 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:MARLESTA MANORFACILITY NUMBER:
079201275
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, ASHLEYFACILITY TYPE:
735
ADDRESS:982 MARLESTA RD.TELEPHONE:
(415) 939-4491
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 6CENSUS: 6DATE:
08/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:ASHLEY FERNANDEZ, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 08/20/24 at 09:50 AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a case management. LPA met with Ashley Fernandez, Administrator, and explained the purpose of the visit.

On 07/29/24, LPA received an LIC 624 regrading the client abuse. LPA reviewed C1’s file, interviewed C1, C2, S2, S3, S4, S5,and S7 LPA requested and received documentation including but not limited to copy of 624, functional capability assessment, IPP, annual Psychological Evaluation, Behaviorist Report, Staff Training's,Termination Letter, Internal Investigation Notes, and Signed Witness Statements.

No deficiencies were cited today.



Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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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