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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600230
Report Date: 10/03/2023
Date Signed: 10/03/2023 12:58:11 PM

Document Has Been Signed on 10/03/2023 12:58 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
SF COASTAL AC/SC, 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:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Carlito Guevarra TIME COMPLETED:
01:15 PM
NARRATIVE
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On October 3, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Caregiver, Mely Garland and Andres Cortez and explained the purpose of the visit. Administrator, Carlito Guevarra joined shortly thereafter.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed living room and dining room to be clean and free from tripping hazards. During this time, residents were sleeping or lying down. Lighting was sufficient and a comfortable temperature of 70 degrees F was maintained. Water temperature throughout the facility bathrooms measured between 144.8- 152.9 degrees F. Bathrooms were equipped with grab bars and non-skid mats. Carbon monoxide monitors are working properly.

LPA toured the facility kitchen. Water temperature measured at 124.7 degrees F. LPA observed there were sufficient two 2 day supply of perishable and seven 7 day supply of non-perishable food present. During the tour LPA observed an expired gallon of milk in the fridge dated 10/1/2023. Chemicals, sharps and medications were observed to be locked an inaccessible to residents. First aid kit was present. Extra linen was observed to be present. Washer and dryer was observed to be in good working condition.

During the visit LPA reviewed 6 resident files and 4 staff files. All were observed to be current and up to date. Staff records are complete with training logs. During resident record review, LPA observed Resident 1's (R1's) physician report to indicate that R1 is allergic to dairy. According to staff interviewed, R1 was provided with cereal for breakfast this morning. According to the administrator, he believes R1 is only allergic to yogurt and sour cream and will confirm with R1's physician and DPOA.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator and a copy is provided with the appeals rights.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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 4
Document Has Been Signed on 10/03/2023 12:58 PM - It Cannot Be Edited


Created By: Komal Charitra On 10/03/2023 at 12:28 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: MARINER'S GREEN RESIDENTIAL CARE
FACILITY NUMBER: 415600230

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as water temperature throughout the facility bathrooms measured between 144.8- 152.9 degrees F and water temperature in the kitchen measured at 124.7 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Facility administrator adjusted water temperature. Water temperature measured between 111 degrees F to 118 degrees F. Deficiency is corrected and cleared during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/03/2023 12:58 PM - It Cannot Be Edited


Created By: Komal Charitra On 10/03/2023 at 12:28 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: MARINER'S GREEN RESIDENTIAL CARE
FACILITY NUMBER: 415600230

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above as LPA observed an expired gallon of milk in the fridge which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2023
Plan of Correction
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Caregiver immediately threw away the gallon of milk in LPAs presence. Deficiency is corrected and cleared during the visit.
Type B
Section Cited
CCR
87555(b)(7)
(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as LPA observed a resident to be allergic to dairy based on physician's report, however facility provided resident with milk for breakfast which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2023
Plan of Correction
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Facility administrator to contact responsible party/DPOA or resident's physician to confirm if resident has a dairy allergy and request for a new physician's report to ensure that staff preparing food. Administrator to provide facility cook training to ensure residents with special diets are being provided with food to meet their dietary needs.
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:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
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