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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600230
Report Date: 07/18/2022
Date Signed: 07/18/2022 11:49:47 AM


Document Has Been Signed on 07/18/2022 11:49 AM - 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:
07/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Caregiver, Mely GarlandTIME COMPLETED:
12:00 PM
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On July 18, 2022, Licensing Program Analyst (LPA) conducted an unannounced case management visit. LPA met with Caregiver, Mely Garland and explained the purpose of the visit.

During the investigation of complaint control number; 14-AS-20220711133013, interviewed staff indicated that the facility did not consult with the resident’s physician’s prior to administering a fluid that was used as a supplement. According to the administrator, he was not aware that the facility had to consult with the physician prior to administering this liquid drink.

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 Caregiver, Mely Garland and a copy is provided with the appeals rights.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
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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Document Has Been Signed on 07/18/2022 11:49 AM - 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
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: 07/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2022
Section Cited

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87465 Incidental Medical and Dental Care: (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file...

Violation of this regulation is not met as evidenced by:
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Based on the interviews conducted, the Administrator admitted to administering R1 fluids without a consent from R1's responsible party which poses a potential health and safety risks to residents in care.
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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) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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