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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201275
Report Date: 09/11/2024
Date Signed: 09/11/2024 02:57:59 PM

Document Has Been Signed on 09/11/2024 02:57 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:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:QUINTIN FENIZA, CARE STAFFTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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On 9/11/2024 at 12:25PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Quintin Feniza, Caregiver and explained the purpose of the visit. The Administrator arrived at approximately 1:00PM. Administrator currently holds a certificate (#6027553735) that expired on 09/15/2025. The facility’s fire clearance was approved for six (6) ambulatory residents.

LPA toured the facility with Quintin Feniza, Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of three (5) total bedrooms. There are two (2) full bathrooms. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared clients’ bathroom was measured at 101.2 degrees Fahrenheit. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/6/2023. Emergency Disaster Plan was last posted on 11/29/2023. First aid kit was observed to be complete. Fire drill was last conducted on 01/10/2024.

Continued on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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: MARLESTA MANOR
FACILITY NUMBER: 079201275
VISIT DATE: 09/11/2024
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Continued from LIC809

Four (4) staff records were reviewed, and all staff have criminal record clearance and 3 holds a current first aid/CPR certificate. four (4) Clients records were reviewed all complete.

LPA requested the following documents to be submitted to CCLD by 09/25/2024.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance


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

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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