385600367-10-18-2024-14-AS-DTOA-DA6TFC-20241018144120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600367
Report Date: 10/18/2024
Date Signed: 10/18/2024 02:41:37 PM

Document Has Been Signed on 10/18/2024 02:41 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:	MARIAN'S CARE HOME I		FACILITY NUMBER:	385600367
ADMINISTRATOR:	CUA, MARIAN TORRES		FACILITY TYPE:	740
ADDRESS:	1450 - 24TH AVENUE		TELEPHONE:	(415) 269-1500
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	6	CENSUS: 5	DATE:	10/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:34 PM
MET WITH:	Bok Eugenio, Caregiver & Marain Torres Cua, Administrator		TIME COMPLETED:	02:55 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	On 10/18/2024, Licensing Program Analyst (LPA) Tobola and Jian conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Caregiver, Bok Eugenio. Administrator, Marian Torres Cua was contacted and arrived later in the visit. The facility currently provides care for 5 residents, none of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located in kitchen was found to be charged. Smoke and carbon monoxide detectors located throughout the facility were in working order. There was a sufficient supply of both perishable and nonperishable foods as required, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished constantly throughout the week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies stored under the kitchen sink were found to be secured. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. During inspection LPA observed resident's (R5) bed to be equipped with two half rails extending the full length of their bed, without physician approval. Licensee contacted R1's physician and will be requesting for an order and exception for R1. There is a single outdoor patio for resident use, all equipped with appropriate shading Continued onto LIC809-C

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARIAN'S CARE HOME I	FACILITY NUMBER: 385600367
	VISIT DATE: 10/18/2024

NARRATIVE

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LPA conducted a sample file review for residents and found that all five residents are in need of updated appraisals. Technical Violation issued. Upon a spot check of staff files, LPA found that caregiver staff have current 1st aid and CPR and annual training completed. However, staff S1 & S2 did not have current health screening on file. Technical Violation issued. Lastly, A spot check of medications was conducted and found that all medication counts and records to be in order.

Marian Toress Cua's Administrator Certificate, 7001432740 is currently active through 8/25/2025.
LPA requested the following documents be sent to CCL by COB 11/1/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Liability Insurance

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2024 02:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARIAN'S CARE HOME I	FACILITY NUMBER: 385600367
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 5 residents found with two half rails extending to the full length of R1's bed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2024
	Plan of Correction
1 2 3 4	Licensee contacted R1's physician and requested for physician's order to grant the use of full length rails for R1's postural support. Licensee to send documentation of physician's order for R1 along with a formal exception request to CCLD by POC date 10/19/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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