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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201364
Report Date: 08/08/2024
Date Signed: 08/09/2024 08:04:41 AM

Document Has Been Signed on 08/09/2024 08:04 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MARINA HOUSE, THEFACILITY NUMBER:
275201364
ADMINISTRATOR/
DIRECTOR:		GRANT, DAWNFACILITY TYPE:
735
ADDRESS:3305 RIO ROADTELEPHONE:
(831) 622-9181
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY: 5CENSUS: 3DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:20 PM
MET WITH:Administrator Dawn GrantTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
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On 08/08/2024 Licensing Program Analyst (LPA) V Gorban arrived unannounced for an Annual Required Inspection. LPA met at the door with Administrator Dawn Grant. LPA stated the purpose of the visit and was allowed entry. During this visit LPA toured facility with AD inside and out. Facility has one entrance point. At the time of the visit there were three clients present.

The facility appeared clean, comfortable temperature recorded at 74 degrees Fahrenheit with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Bathrooms have trashcans with lids. The exterior tour was conducted. The facility licensed for six private rooms. Every room is fully furnished. LPA reviewed clients files including for emergency contact and physician report.

Kitchen observed with free of clutter and obstruction. Sharp items placed away and locked. The kitchen refrigerator was checked. LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored.

Cleaning supplies were observed to be locked in a hallway cabinet. Records were reviewed for infection control training. Fire extinguisher in compliance, service date 08/18/2023.

Medications were observed to be locked in med cabinet located in the kitchen. Facility uses to document file for administration, dispense, document and track clients’ medications. First aid kit was observed and contained all required items.
Carbon monoxide and smoke detectors were tested and observed to be operational.

Report continues on attached LIC809-C
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MARINA HOUSE, THE
FACILITY NUMBER: 275201364
VISIT DATE: 08/08/2024
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Exit interview was conducted. No citations were issued on this visit. Copy of this report printed and provided for facility records.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Residential Facility (ARF):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Administrator Certificate


Please submit the above forms/information to Fresno CCL by: 08/12/2024.

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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