336425952-9-4-2024-18-AS-VMIN-D8SQWW-20240904123236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425952
Report Date: 09/04/2024
Date Signed: 09/04/2024 12:32:43 PM

Document Has Been Signed on 09/04/2024 12:32 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MARCELINE'S HOME CARE		FACILITY NUMBER:	336425952
ADMINISTRATOR:	SANGIAN, MARCELINE & JAN		FACILITY TYPE:	740
ADDRESS:	136 GARCIA DR.		TELEPHONE:	(951) 665-3045
CITY:	SAN JACINTO	STATE: CA	ZIP CODE:	92582
CAPACITY:	6	CENSUS: 6	DATE:	09/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	ADMINISTRATOR, JAN SANGIAN		TIME COMPLETED:	12:39 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 September 04, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Administrator, Jan Sangian. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for six, Elderly Adult Residents and is currently operating at 100% capacity of six, Elderly Adults (740), Facility Type.

LPA Mixson toured the facility along with Administrator, and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home located at 136 Garcia Dr. San Jacinto, CA. 92582.

Physical Plant: The facility phone number is (951) 665-3045 and it is operable. LPA Mixson observed the four residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something" Ombudsman's and the "Personal Rights." The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MARCELINE'S HOME CARE	FACILITY NUMBER: 336425952
	VISIT DATE: 09/04/2024

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

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked.

Care & Supervision: Facility has sufficient staff, currently two staff and six of six residents participating in family visits, meeting with Hospice Nurse, and other activities and the noon day meal. Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted monthly and logged. Administrator Certificate for Levin Sangian is current and does not expire until 11/07/2025.

Facility tests and logs water regularly: Water was tested and logged on today and tested within regulations. Fire extinguishers are charged and in the green.

Training and Administrator Certificate: LPA reviewed administrator’s certification and it was current at the time of this visit with an expiration in 11/07/2025. Training is done in person every month by a certified Administrator.

Records Review: LPA Mixson reviewed resident and staff files, conducted two staff interviews, and two resident interviews. LPA Mixson reviewed current two staff records and those reviewed have current Criminal Background Clearance, current First Aid and CPR certification, and training's are current. Two residents records were reviewed and contained required documents. Physician reports are current and TB test were completed at the time of admission. LPA reviewed previous CCL forms.

There was no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was discussed and given to Administrator, Jan Sangian.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2