<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803883
Report Date: 10/14/2022
Date Signed: 10/14/2022 02:07:49 PM

Document Has Been Signed on 10/14/2022 02:07 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 75DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Pete Konicek, DirectorTIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/14/2022, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Creative Arts Director, Tim Park and Director, Pete Konicek. The facility currently provides services for 75 clients; 54 of which of which were present participating in-person and remaining clients by remote services. Facility has contracted with R&D Transportation Services for client transportation with COVID safety protocols for client symptoms assessment prior to boarding facility vehicles as well as arrival to the program site. Facility conducts emergency fire drills on a monthly basis and are recorded. Fire extinguishers located throughout the facility last charged on 2/14/2022. Director will provide CCL with updated Fire Inspection records for smoke and carbon monoxide detectors and sprinkler system.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Director; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA observed all clients to be engaged in various activities including arts, movies and music sessions. Staff provide activity supplies to clients who participate remotely for full engagement and participation. Staff appear to be assisting clients and providing support during a tour of the facility. Sample file review was conducted for all staff present during the visit. LPA found all reviewed 6 of 6 staff to have current 1st Aid & CPR training certification on file.

Cleaning supplies were all located in a secured staff offices and supply closets. Several restrooms accessible to clients were inspected and found to be in clean and sanitary condition. Kitchen and food supply areas were also inspected and found to be in order with food items properly stored. Clients bring personal lunches stored in the kitchen area with snacks available throughout the day.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MARIN VENTURES
FACILITY NUMBER: 216803883
VISIT DATE: 10/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Infection Control:
Facility has submitted a infection control plan to CCLD for review. Facility has a station at main entrance with a sign in sheet in place, hand sanitizer and other items designated for clients and staff. Staff and clients are screened on a daily basis and based on change of condition. Facility continues to surveillance test all staff once a week and implement the use of N95 respirator masks for all staff who provide direct client supervision.

LPAs requested for facility updated records to be submitted to CCLD by COB 10/28/2022:

- Fire Inspection Report
- Designation of Responsibility
- Administrative Organization
- Personnel Report
- Emergency Disaster Plan
- Transportation Procedures
- Theft and Loss Policy

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2