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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500295
Report Date: 07/03/2024
Date Signed: 07/03/2024 01:14:18 PM

Document Has Been Signed on 07/03/2024 01:14 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HERITAGE ON THE MARINAFACILITY NUMBER:
380500295
ADMINISTRATOR/
DIRECTOR:		MARY LINDEFACILITY TYPE:
741
ADDRESS:3400 LAGUNA ST.TELEPHONE:
(415) 202-0300
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94123
CAPACITY: 109CENSUS: 82DATE:
07/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Martha Nkhoma, Executive Director of Resident Health and Mary Linde, Chief Executive Officer TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On July 3, 2024, Licensing Program Analyst (LPA) John Calandra arrived at the facility at 9:15 AM to complete the Annual 1-year required inspection. LPA Calandra was greeted by Mary Linde, Chief Executive Officer (CEO) and Martha Nkhoma, Executive Director of Resident Health and explained the purpose of the visit.

LPA Calandra reviewed 5 staff files. All were observed to be complete.

LPA Calandra also reviewed Centrally Stored Medication Records. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

LPA Calandra interviewed 3 residents and 3 staff

No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Mary Linde, Chief Executive Officer and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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