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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600230
Report Date: 03/13/2024
Date Signed: 03/13/2024 12:54:52 PM


Document Has Been Signed on 03/13/2024 12:54 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:
03/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Carlito GuevarraTIME COMPLETED:
01:15 PM
NARRATIVE
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On March 13, 2024, 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 the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. LPA observed six private resident rooms, with half bathrooms in five of the resident rooms. Required furniture was observed in resident rooms. Bathrooms were observed to be in good repair, odor-free; equipped with liquid soap, non-skid mats, and paper-towels. Living rooms and dining room was free from tripping hazards. Kitchen was observed; chemicals, sharps and medications were locked an inaccessible to residents. Two day perishable and seven day non-perishables were present. Water temperature throughout the facility measured between 110-112 degrees F. LPA toured the garage and observed washer and dryer in good working condition. LPA observed storage cabinets built in the garage.

Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of January 2023. Emergency drills are logged and done every three months. Extra linen and first aid kit was observed present. LPA reviewed 5 resident records and 4 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties. Report is reviewed with Assistant administrator and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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 03/13/2024 12:54 PM - 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
SF COASTAL AC/SC, 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: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA toured the garage and observed storage cabinets built which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2024
Plan of Correction
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Licensee/Administrator to contact the Redwood City Building Department regarding built storage cabinets. Licensee/Administrator will notify CCL of what Building Department indicate and submit a plan of correction in writing.
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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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