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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200737
Report Date: 08/05/2022
Date Signed: 08/05/2022 04:19:42 PM


Document Has Been Signed on 08/05/2022 04:19 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:CALIFORNIA MENTOR-MARINEVIEW HOMEFACILITY NUMBER:
019200737
ADMINISTRATOR:JOE FARRISHFACILITY TYPE:
740
ADDRESS:2420 MARINEVIEW DRIVETELEPHONE:
(916) 300-9510
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:4CENSUS: 4DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Joseph Farrish, AdministratorTIME COMPLETED:
04:30 PM
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On 8/5/22 at 2:10 PM, Licensing Program Analysts (LPAs) K. Nguyen and L. Francisco arrived unannounced to conduct Infection Control Inspection. LPAs met with Direct Support Professional, Lucky Amenaghawon, and explained the purpose of the visit. Joseph Farrish Administrator later arrived at 2:42pm during the visit. LPA continued the inspection with Joseph.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient of non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 8/12/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610D Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

Exit interview conducted. A copy of this report is provided


SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
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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