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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804205
Report Date: 03/14/2024
Date Signed: 03/14/2024 10:31:11 AM

Document Has Been Signed on 03/14/2024 10:31 AM - 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MARINWOOD HOMECARE INC-HEATHERSTONE HOMEFACILITY NUMBER:
216804205
ADMINISTRATOR:LIU, FENGFACILITY TYPE:
735
ADDRESS:2709 HEATHERSTONE DRIVETELEPHONE:
(415) 305-1825
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: DATE:
03/14/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Liu, FengTIME COMPLETED:
10:30 AM
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Facility Type: ARF
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Liu, Feng
Interview Method: Telephone interview

On March 14, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program

2. Day Program/ Activities/ Facility coverage

3. Staffing requirements & Training

54. General provisions / readiness for pre licensing inspection

SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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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