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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803883
Report Date: 10/01/2024
Date Signed: 10/01/2024 04:05:06 PM

Document Has Been Signed on 10/01/2024 04:05 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MARIN VENTURESFACILITY NUMBER:
216803883
ADMINISTRATOR/
DIRECTOR:		RAYMOND CASHELFACILITY TYPE:
775
ADDRESS:10 JOSEPH COURTTELEPHONE:
(415) 472-4961
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 75CENSUS: 36DATE:
10/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Administrator, Joe CashelTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required - 1 Year Visit, and met with Administrator, Joe Cashel. Facility is an Adult Day Program that provides activities to Individuals with Disabilities. Facility has an approved fire clearance and capacity for 75 ambulatory clients, of which 30 clients can be non-ambulatory. Upon arrival, LPA was informed that there were currently 36 Clients at Day Program and 14 staff members on-site.

At approximately 10:10AM, LPA reviewed the Facility's Staff Roster and found that Staff Member 1 (S1) was not fingerprint cleared or associated to the facility as required. Administrator notified S1 to leave the premises (deficiency cited and civil penalty issued, see LIC809D and LIC421BG, Health and Safety Code 1522(c)(1)). At approximately 11:00AM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 4 activity rooms, 6 bathrooms and common areas. Facility has an Infection Control plan on file. There was an appropriate supply of cleaning products, hygiene products and paper products available for clients. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Per Administrator, clients bring their own snacks and lunches to program. Facility does not manage P&I monies. During walkthrough, LPA and Administrator observed the following to be unlocked and accessible to clients in care: Lysol disinfectant spray, biodegradable Tide Pods, and cleaning spray (deficiency cited, see LIC809D, regulation 82087(a)(3)).

LPA reviewed staff and client files, and client medications. Staff files were all found to be well organized, thorough and contained the required documentation, and had current First Aid and CPR certification. During client file review, LPA observed the following: 1 of 8 client files did not have an Admissions Agreement, 2 of 8 client files did not have a current Individual Service Plan, 5 of 8 client files did not have a Medical Assessment/Physician's Report, and 6 of 8 clients did not have proof of a negative TB test (deficiencies cited and technical advisories/violations issued, see LIC809D and LIC9102, regulations 82068(a), 82068.3(a), 82069(a), 82069(b)(1)).

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MARIN VENTURES
FACILITY NUMBER: 216803883
VISIT DATE: 10/01/2024
NARRATIVE
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Continued from LIC809

During medication review, LPA observed that the facility is not centrally storing medication for clients. Per conversation with staff, the medications are kept on-site and are not taken home at the end of the day. LPA discussed and reviewed centrally stored medications log with staff (see technical violation, LIC9102, regulation 82075(l)(3)). Facility's fire extinguishers were last inspected December 2023. Facility's last emergency/disaster drill was conducted August 2024. Facility has a hard wired fire alarm and sprinkler system that is directly connected to the local Fire Department. Facility's fire system was last inspected April 2024.

LPA requested the following documents to update facility file:

  • Designation of Facility Responsibility (LIC 308)
  • Updated Emergency Disaster Plan (LIC 610D)
  • Updated Liability Insurance

Documents to be submitted to Community Care Licensing (CCL) by due date of 11/01/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

***An immediate civil penalty assessment in the total amount of $100.00 has been issued for a lack of criminal
record clearance and/or associations as required for S1 (See LIC 421BG).

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC811 (Confidential Names) Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 8 of 8
Document Has Been Signed on 10/01/2024 04:05 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 10/01/2024 at 03:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MARIN VENTURES
FACILITY NUMBER: 216803883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observations made, Licensee did not comply with the section cited above. Licensee did not ensure that Staff Member 1 (S1) had the proper background clearance and/or association required to provide care at the facility. This poses an immediate health and safety risk to clients in care.
POC Due Date: 10/03/2024
Plan of Correction
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Licensee to ensure that individuals subject to a criminal record review receive proper clearance and are associated to facility per Title 22 regulations. Licensee to submit a detailed step by step plan for how they will ensure fingerprint clearance and association is complete for an employee prior to them working. Plan to be submitted by POC due date of 10/03/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 10/01/2024 04:05 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 10/01/2024 at 03:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MARIN VENTURES
FACILITY NUMBER: 216803883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. LPA and Administrator observed the following toxins/cleaning supplies unlocked and accessible to clients in care: Lysol disinfectant spray, biodegradable Tide Pods, and cleaning spray. This poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee to conduct in-service training for all direct care staff reviewing Regulation 82087(a)(3). Training to review items that are inaccessible to clients in care and to review proper storage of items. Licensee to submit training to CCL that includes the following: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 10/11/2024.
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on client file review, Licensee did not comply with the section cited above. LPA observed that 5 of 8 clients did not have a medical assessment/Physician's Report on file. This poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee to submit a step by step plan on how they will comply with Regulation 82069(a) and ensure that clients have their medical assessments conducted timely. Licensee to submit proof of medical assessment/Physician's Reports for the identified 5 clients to CCL by POC due date of 10/11/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 10/01/2024 04:05 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 10/01/2024 at 03:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MARIN VENTURES
FACILITY NUMBER: 216803883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on client file review, Licensee did not comply with the section cited above. LPA observed that 6 of 8 clients did not have proof of a negative TB test on file. This poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee to submit a step by step plan on how they will comply with Regulation 82069(b)(1) and ensure that clients have their TB tests conducted timely. Licensee to submit proof of negative TB Tests for the identified 6 clients to CCL by POC due date of 10/11/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


LIC809 (FAS) - (06/04)
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