<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600367
Report Date: 11/18/2025
Date Signed: 11/18/2025 02:38:00 PM

Document Has Been Signed on 11/18/2025 02:38 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 IFACILITY NUMBER:
385600367
ADMINISTRATOR/
DIRECTOR:		CUA, MARIAN TORRESFACILITY TYPE:
740
ADDRESS:1450 - 24TH AVENUETELEPHONE:
(415) 269-1500
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 6CENSUS: 6DATE:
11/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Maritess Dator, House Manager and Marian Torres Cua, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:45 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 11/18/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Maritess Dator, Caregiver/House Manager and explained the purpose of the visit. Marian Cua Torres, Administrator/Licensee arrived later during the visit.

LPA toured the physical plant, this is a 2-story building with 8 bedrooms(6 for residents and 2 for staff), 2 bathrooms, a living room, dining room, garage, backyard, and Kitchen. All bedrooms had the required furniture and sufficient lighting. The facility's fire alarms and Carbon Monoxide Detectors were observed to be in working order. The facility's fire extinguisher was observed to be fully charged. The facility's hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility's first aid kit had the required items.

All sharp objects, soap, and poisons were observed to be locked and in-accessible to persons in care.

LPA reviewed 5 resident files and 3 staff files. All staff files were complete, but resident files were missing Appraisal of Needs and Services, Preplacement Appraisals, and Functional Capability Assessments.

This facility does not handle cash resources for residents.

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.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
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: 11/18/2025
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
LPA requested the following documents be sent to the Department by 11/25/2025: LIC 500(Personnel Summary Report), Administrative Organization(LIC 309), Health Screening Reports(All staff), Job Description/Personnel Policies and On the Job Training, Liability Insurance, Administrator Certificate(when received), Dementia Plan of Operation, and Transportation Procedures.

During the physical plant tour, LPA observed that R1 had a full bed rail on their bed. Per interview with Licensee, the full bed rail is used at night for R1. While a bed rail that only extends half of the length of the bed is allowed for mobility purposes with a physician's order, a bed rail that extends the entire length of the bed is not allowed as it is considered a type of restraint. A Type A citation was issued for this deficiency.

In addition, while reviewing files, LPA noticed that none of the five resident files reviewed had an Appraisal of Needs and Services or preplacement Appraisal. A Type B citation was provided for this deficiency.

During file review, LPA observed that the facility did not have documentation of their latest fire/emergency drill which per Title 22 regulations shall be conducted on a quarterly basis. A Type B citation was provided for this deficiency.

Deficiencies are cited under the California Code of Regulations(CCR), Title 22. Failure to correct the Deficiencies by the Proof of Correction(POC) due date may result in Civil Penalties.

During the visit, Licensee/Administrator expressed interest in signing up for the Department's Technical Support Program. LPA explained the program in detail and provided the website to the Licensee to sign up.

An exit interview was conducted. This report was reviewed with facility representatives and a copy along with Appeal Rights provided.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/18/2025 02:38 PM - It Cannot Be Edited


Created By: John Calandra On 11/18/2025 at 12:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
87608(a)(5)(B) Postural Supports: Based on the individual's preadmission appraisal, and subsequent changes to that appraisal…Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving…(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 observation and interview, the Licensee is allowing R1 to utilize bed rails that extend the entire length of their bed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2025
Plan of Correction
1
2
3
4
Licensee will immediately replace the bed with another that does not have bed rails extending the entire length of the bed and will apply for an exception for R1.
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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/18/2025 02:38 PM - It Cannot Be Edited


Created By: John Calandra On 11/18/2025 at 01:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
HSC 1569.695(e)(2) Emergency Plans: (e) A facility shall have all of the following information readily available to facility staff during an emergency: An appraisal of Needs and Services.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not have an appraisal of resident needs and services plan for 5 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2025
Plan of Correction
1
2
3
4
Licnesee will create an Appraisal of Resident Needs and Services plan for all 5 residents and have a meeting with family to discuss the appraisals. Licensee will send copies of the signed appraisals to the Department by the POC due date listed above.
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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/18/2025 02:38 PM - It Cannot Be Edited


Created By: John Calandra On 11/18/2025 at 01:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not have a preadmission appraisal for 5 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2025
Plan of Correction
1
2
3
4
Licensee will create Preadmission Appraisals for all 5 residents and send copies to the Deparment by the POC due date listed above.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee for not conducting a quarterly emergency drill, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2025
Plan of Correction
1
2
3
4
Licensee will conduct an emergency drill and provide documentation to the Department including names of individuals that participated, date of the drill, and subject of the emergency drill by the POC due date listed above.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
Page: 6 of 6