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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803883
Report Date: 09/09/2021
Date Signed: 09/09/2021 01:37:26 PM

Document Has Been Signed on 09/09/2021 01:37 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MARIN VENTURESFACILITY NUMBER:
216803883
ADMINISTRATOR:KONICEK, PETEFACILITY TYPE:
775
ADDRESS:10 JOSEPH COURTTELEPHONE:
(415) 472-4961
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 75CENSUS: 23DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Creative Arts Director, Tim ParkTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Marin Ventures for the purpose of conducting an Unannounced Required 1 year inspection. LPA was met at the door by Creative Arts Director, Tim Park who granted access into the facility.

LPA toured the facility. Facility is a one floor building. Hot water temperature checked between 113.0 - 117.3 degrees F. The facility has a phone line designated for client use. There was an ample supply of personal hygiene products. Personnel records and client records are stored at the facility office area. The main floor includes kitchen equipped with a small refrigerator; art, drawing & painting room, conference room, activity room, storage, offices, laundry, and client's & staff bathrooms. Activities pre-planned & clients will opt where to go once at the facility. Client & staff records, medication, first aid supplies, and toxins are locked and inaccessible on this level. There are six restrooms on this floor designated as female & male with two having a changing room. Clients will bring their own food and food will be provided for plan celebrations. Facility will not handle P&I. Motor vehicle to be used to transport clients inspected to ensure safe operating condition and will be offered if needed.

LPA requested the following documents to be sent to Community Care Licensing: LIC 309, LIC 400, LIC 308, LIC 500, LIC 402 (Surety Bond if applicable), maintenance record for the vehicles, and Liability Insurance.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE in the office and attic. Facility is in the process of being N95 Fit tested.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Pete Konicek.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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