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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500295
Report Date: 05/26/2021
Date Signed: 05/26/2021 03:08:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HERITAGE ON THE MARINAFACILITY NUMBER:
380500295
ADMINISTRATOR:MELVIN MATSUMOTOFACILITY TYPE:
741
ADDRESS:3400 LAGUNA ST.TELEPHONE:
(415) 202-0300
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94123
CAPACITY:109CENSUS: 73DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Hanh Ta and Sandra PeretTIME COMPLETED:
03:10 PM
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On 05/26/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required inspection. At 1:30 PM, LPA met with a staff member at the entrance of the facility. LPA underwent a health screening following the facility's entrance safety procedures. LPA also had his temperature checked and logged and then signed into the facility.

At 1:40PM, Administrator Hanh Ta and Infection Preventionist Sandra Peret met with LPA Filouane. LPA introduced himself and announced the 1-year required inspection.

At 1:55 PM, LPA toured the physical plant. The physical plant is consistent with the submitted facility sketch/floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. The kitchen is sanitary and organized. At approximately 2:30 PM, LPA observed the refrigerator and freezer was stocked with fruits, vegetables, meat, eggs, and bottled water. LPA observed the facility's emergency food supply as sufficient.

The clients' bedrooms were inspected and all had required lighting and furniture.
Facility is equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguishers as current. The facility's first aid kit included the required tweezers, scissors, and a thermometer. During the facility tour, LPA observed the bathrooms are clean and sanitary. The facility bathrooms had the required hand washing signage. Cleaning solutions are stored and locked. PPE is stocked and current.

At 2:40 PM, LPA completed the facility tour for Infection Control. This report was reviewed with the Administrator and the Infection Preventionist. No deficiencies were cited today.

Exit interview conducted with the Administrator and Infection Preventionist. Due to technical difficulties, a copy of this report will be emailed to the Administrator.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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