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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
380500295
Report Date:
10/02/2023
Date Signed:
10/02/2023 08:06:31 PM
Document Has Been Signed on
10/02/2023 08:06 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:
74
DATE:
10/02/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:52 AM
MET WITH:
Mary Linde
TIME COMPLETED:
11:30 AM
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LPA Grace Donato conducted an unannounced case management visit to the facility. LPA met with Administrator Mary Linde. LPA explained the purpose of today's visit.
This case management visit is with regards to the exception submitted to the department for one resident who depend on others for all activities of daily living.
LPA assessed the resident
in his/her room. The resident was assessed if he/she is able to do activities with assistance or do it on his/her own.
No deficiencies are cited during the visit. Report is reviewed with the administrator 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:
10/02/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/02/2023
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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