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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500295
Report Date: 06/22/2023
Date Signed: 06/26/2023 09:09:27 AM


Document Has Been Signed on 06/26/2023 09:09 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HERITAGE ON THE MARINAFACILITY NUMBER:
380500295
ADMINISTRATOR:MARY LINDEFACILITY TYPE:
741
ADDRESS:3400 LAGUNA ST.TELEPHONE:
(415) 202-0300
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94123
CAPACITY:109CENSUS: 80DATE:
06/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Mary LindeTIME COMPLETED:
12:30 PM
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LPA Grace Donato & LPM Jackie Jin conducted an unannounced case management visit to the facility. LPA & LPM met with Mary Linde, administrator.

This case management visit is with regards to the exception submitted to the department for 2 residents who depend on others for all activities of daily living.

LPA & LPM assessed the 2 residents during activities and lunch time. The residents were assessed if they are able to do activities with assistance or do it by themselves.

No citations given for todays visit. A copy if this report is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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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