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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600230
Report Date: 03/18/2022
Date Signed: 03/18/2022 02:39:34 PM

Document Has Been Signed on 03/18/2022 02:39 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
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:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caregiver, Mely Garland TIME COMPLETED:
03:00 PM
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On March 18, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA was greeted by Caregiver, Mely Garland and explained the purpose of the visit. LPA was screened at entry point and the Caregiver was able to provide screening log documentation for residents, staff and visitors.
Upon arrival, LPA observed COVID signage on the front door but LPA discussed the need to add more reminder signage (masking, COVID symptoms, social distancing, cough etiquette) on the front door.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are present: entry procedures, daily monitoring for residents and staff, and 30-day PPE supply. LPA observed the COVID signage posted throughout the facility. This is a single story with 7 bedrooms (6 private rooms for residents and 1 staff room), 2 full and 4 half bathroom. It is noted that the facility floor plan that was received by CCLD on June 28, 2000, shows a staff room (Room #6). LPA observed the staff room to have a built in structure to accommodate two separate private bedrooms. A new fire clearance will be needed.

LPA observed the bathrooms to be equipped with liquid hand soap, hand washing signs, and covered trash cans. LPA Charitra indicated that hand-towels and bath-towels should not be present in the bathrooms. LPA toured the kitchen and advised caregiver to switch out hand-towels for paper-towels and disinfectant wipes.

LPA observed 2 day perishable and 7 day non-perishable. Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. During the visit LPA observed 3 residents maintaining social distancing while watching television in the living room.

LPA requests for the following to be sent to CCLD by 3/25/22:
  • LIC308 Designation of Administrative Organization
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610D Emergency Disaster Plan
  • New facility floor plan

No citations will be issued during this visit. Report reviewed with Caregiver and a copy will be provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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