415600850-9-14-2021-14-AS-MHAN-C6UQBT-20210914120205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600850
Report Date: 09/14/2021
Date Signed: 09/14/2021 05:56:09 PM

Document Has Been Signed on 09/14/2021 05:56 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:	MARINOL SENIOR CARE I		FACILITY NUMBER:	415600850
ADMINISTRATOR:	SUICO, MARIGOLD		FACILITY TYPE:	740
ADDRESS:	768 LUNDY WAY		TELEPHONE:	(650) 557-1227
CITY:	PACIFICA	STATE: CA	ZIP CODE:	94044
CAPACITY: 6		CENSUS: 3	DATE:	09/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee, Nancy Uy		TIME COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/14//2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual required inspection. LPA met with the Licensee, Nancy Uy. At 10:00am, LPA arrived at facility and was greeted by staff. LPA observed COVID-19 signs posted on the front entry point and but LPA was not screened at the entry point and the caregiver stated that the thermometer was broken and the Licensee was getting a replacement. There was also no screening station set up by the entry point. At 10:30 am, LPA reviewed the COVID-19 screening logs and it was incomplete. There was no documentation showing that staff and residents were screened daily. There was one resident screening log for June but there was no year documented on the log and it showed that 6 residents were screened for 11 days in June. The rest of the logs were scattered and uncleared as to what month and what year that the screening was completed. At 11:00 am, LPA toured the facility beginning in the dining room and observed 1 sofa and 3 recliner single sofas that are spaced out to promote social distancing. COVID-19 Infection Control signs are posted in the living/dining room but not in the hallway. LPA recommended to post COVID-19 signs in the hallway as well. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels, and hand washing instruction is posted by the door. Trash cans are observed not having a lid; LPA recommended to have trash cans with foot operated lids. All rooms are private except for one and the beds are at least 6" apart from each other (currently there is only 1 resident in that room). This report is continued on to LIC 809C

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

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 09/14/2021 05:56 PM - It Cannot Be Edited

Created By: Murial Han On 09/14/2021 at 11:03 AM

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: MARINOL SENIOR CARE I	FACILITY NUMBER: 415600850
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in all Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. There is no documentation for the daily COVID-19 screening process is being done for staff and residents. Licensing Program Analyst (LPA) Murial Han was not screened at the entry point for COVID-19 and there was no screening station set up by the entry.
	POC Due Date: 09/21/2021
	Plan of Correction
1 2 3 4	The Administrator and/or Licensee will review the screening requirements, and educate staff members on the daily COVID-19 screening process. The Administrator will sent a copy of the education record and the lesson plan to the Regional Office by 9/21/2021 In addition, the Administrator and/or Licensee will set up the screening station by the central entry point by 9/21/2021

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Montes

LICENSING EVALUATOR NAME:

Murial Han

LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

LIC809 (FAS) - (06/04)

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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: MARINOL SENIOR CARE I	FACILITY NUMBER: 415600850
	VISIT DATE: 09/14/2021

NARRATIVE

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Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kits are inspected and complete. There are 3 residents, 1 staff members, the Licensee present during the inspection.

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Licensee, Nancy Uy. A copy of the report and Appeal Rights provided.

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

LIC809 (FAS) - (06/04)

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