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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600230
Report Date: 03/24/2026
Date Signed: 03/24/2026 02:05:11 PM

Document Has Been Signed on 03/24/2026 02:05 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MARINER'S GREEN RESIDENTIAL CAREFACILITY NUMBER:
415600230
ADMINISTRATOR/
DIRECTOR:		GUEVARRA, ANALIZA B.FACILITY TYPE:
740
ADDRESS:380 ENSIGN LANETELEPHONE:
(650) 591-6115
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY: 6CENSUS: 6DATE:
03/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Caregiver, Mely Garland TIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On March 24, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual visit. LPA met with Caregiver, Mely Garland and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single story facility. There are 6 resident bedrooms, all of which were observed to be private rooms equipped with all required furnishings. During the visit, LPA observed resident rooms #1, #2, and #4 to have beds equipped with half bed rails and room #5 to be equipped with a full bed rail. The residents in the specified with bed rails did not have a physician's order for it. In addition, resident in room #3 was observed to be bedridden, however facility does not have bedridden fire clearance. LPA observed 2 full bathrooms and 4 half bathrooms. Bathrooms were clean and odor-free. Water temperature throughout the facility measured between 105-107 degrees F.

Living room and dining room was free from tripping hazards. A comfortable temperature was maintained and lighting was sufficient for comfort. LPA observed two day perishable and seven day non-perishables. Chemicals, medications and sharps were locked and inaccessible to residents in care. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of January 2026. Emergency drills are logged and done every 3 months. LPA reviewed 5 resident records and 5 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 caregiver and a copy is provided with the civil penalty and appeal rights.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Curley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/24/2026 02:05 PM - It Cannot Be Edited


Created By: Komal Curley On 03/24/2026 at 01:32 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviewed, resident 2 (R2) in Room 2 was observed to be bedridden per physician's report, however according to the facility license, facility does not have a fire clearance for bedridden residents which poses an immediate health, safety or personal rights risk to persons in care. An immediate $500.00 civil penalty is being issued during the visit.
POC Due Date: 03/25/2026
Plan of Correction
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Licensee/administrator shall reach out to the fire department by 3/25/26 and notify them of R2 being bedridden. Licensee/administrator shall submit a new LIC200 with a new floor plan indicating what rooms to be used as bedridden so CCL can submit to fire deparment for a new clearance. Licensee/administrator shall reach out to R2's physician to clarify ambulation status as caregivers indicated R2 is ambulatory.
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and records reviewed, Resident rooms #1, #2, and #4 had beds equipped with half bed rails and room #5 to be equipped with a full bed rail. The residents in the specified with bed rails did not have a physician's order for it which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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Licensee/administrator shall remove half bed rail until residents in rooms #1, #2 and #4 have a written order from their physicians indicating the need for a postural support.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/24/2026 02:05 PM - It Cannot Be Edited


Created By: Komal Curley On 03/24/2026 at 01:48 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: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review, resident 5 (R5) in room #5 had a bed with a full bed rail, however is not on hospice which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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Licensee/administrator shall remove the full bed rails from R5's bed and consult with R5's family and physician to discuss other options for R5.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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