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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600230
Report Date: 06/17/2021
Date Signed: 06/17/2021 02:29:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MARINER'S GREEN RESIDENTIAL CAREFACILITY NUMBER:
415600230
ADMINISTRATOR:GUEVARRA, ANALIZA B.FACILITY TYPE:
740
ADDRESS:380 ENSIGN LANETELEPHONE:
(650) 591-6115
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY:6CENSUS: 6DATE:
06/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Carlito GuevarraTIME COMPLETED:
02:35 PM
NARRATIVE
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On June 17, 2021, at 1:10pm, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced case management in response to an incident that the facility self-reported regarding a resident AWOL (Absent Without Official Leave). LPA met with caregiver Mely Garland, Licensee Carlito Guevarra showed up at a later time. CCLD was informed of this incident on June 14, 2021. LPA was provided with Resident 1's (R1) physician report prior to this case management.

LPA interviewed caregiver (S1) and toured the facility. LPA opened each sliding door in resident's rooms along with garage door. Each door has an auditory device to monitor exits. S1 stated that R1 unlocked the garage door and went out of the facility when S1 and Staff 2 (S2) were attending to another resident. S1 and S2 did not hear the auditory device when the door opened, and this is when R1 went missing for 1 hour and 45 minutes.

A deficiency of the California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87464 is observed and cited on the following LIC809-D page. Appeal Rights given.

This report was discussed and reviewed with Licensee Carlito Guevarra.

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARINER'S GREEN RESIDENTIAL CARE
FACILITY NUMBER: 415600230
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2021
Section Cited

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87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
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This requirement is not met as evidenced by: based on interviews and documentation, Licensee did not ensure basic services were being met, due to lack of supervision allowing resident to AWOL, which poses an immediate health, safety and personal rights risk to residents
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021
LIC809 (FAS) - (06/04)
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