380500295-6-14-2023-14-AS-GDOO-CSSVXW-20230614165015

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380500295
Report Date: 06/12/2023
Date Signed: 06/14/2023 04:50:43 PM

Document Has Been Signed on 06/14/2023 04:50 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	HERITAGE ON THE MARINA		FACILITY NUMBER:	380500295
ADMINISTRATOR:	MARY LINDE		FACILITY TYPE:	741
ADDRESS:	3400 LAGUNA ST.		TELEPHONE:	(415) 202-0300
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94123
CAPACITY:	109	CENSUS: 80	DATE:	06/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Karina Tapia & Michael Russel		TIME COMPLETED:	05:30 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	LPA Grace Donato & LPM Jackie Jin conducted an unannounced annual visit to the facility. LPA & LPM met with the Director of Resident Life, Karina Tapia and Resident Health Services Director, Michael Russel. Mary Linde, administrator, arrived towards the end of the visit. LPA & LPM toured the facility inside and outside including a random sample of resident apartments, common areas, and kitchen area. LPA and LPM observed some residents were at the dining room having lunch. There were also residents doing activities in the hallway and in the activity rooms. While touring the facility it was observed that the temperature was at 78 deg F. Hot water was also tested in the resident apartments and the temperature was 110 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. Resident call lights were checked and functioning. LPA and LPM toured the kitchen and it was observed that anyone entering the kitchen are required to wear hairnets. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Four resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA interviewed 3 residents and 3 staff. All residents stated that they are being well taken care of and enjoys the food. Activities are offered to residents, however they are given the choice to join. All staff are compentent with regards to the care of the residents.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HERITAGE ON THE MARINA	FACILITY NUMBER: 380500295
	VISIT DATE: 06/12/2023

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

During the tour, in one of the residents’ apartments, it was observed that there was prescribed medication and vitamin supplements in an unlocked bathroom cabinet. Resident Health Services Director removed the medication right away and locked it up in the medication room.

LPA requested licensee to submit the following by 6/17/2023:

LIC 309 Administrative Organization
LIC 610E Emergency Disaster Plan

No deficiencies are cited at this time. A technical violation was given. Report is reviewed with Administrator Resident Health Services Director and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2