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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600850
Report Date: 08/03/2022
Date Signed: 08/03/2022 07:44:16 PM


Document Has Been Signed on 08/03/2022 07:44 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:MARINOL SENIOR CARE IFACILITY NUMBER:
415600850
ADMINISTRATOR:SUICO, MARIGOLDFACILITY TYPE:
740
ADDRESS:768 LUNDY WAYTELEPHONE:
(650) 557-1227
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY:6CENSUS: 3DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Nancy UyTIME COMPLETED:
11:30 AM
NARRATIVE
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On 8/3/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator, Nancy Uy and explained the purpose of the inspection.

LPA toured facility and grounds. 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, containment strategies (the facility has dedicated a private room for isolation and quarantine). There are 3 male residents at the facility. The facility has 1 semi-private room with beds observed to be 6" apart and 4 private rooms. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and LPA recommended to remove cloth towels and replace them with paper towels. Hand washing instructions posted by the sink.

Medications, and toxins stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety. First-aid kit is inspected and complete.

Based on the documents provided, LPA observed facility stopped conducting the daily resident COVID-19 screening back in November 2021 and the facility was not able to provide any documentation on staff daily COVID-19 screening. According to the staff, they were not aware that these processes needed to be continued on a daily basis.

Deficiency is observed and cited on a LIC 809Ds. Failure to correct the deficiencies may result in civil penalties.

During the inspection, LPA requested documents to update administrator- A written letter from the Licensee appointing the current administrator for the facility, administrator certification, LIC 500, LIC 501 and LIC 308 to be submitted to CCL by 8/8/2022.

This report is reviewed and discussed with the administrator. A copy of this report and Appeal Rights were provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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 08/03/2022 07:44 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: MARINOL SENIOR CARE I
FACILITY NUMBER: 415600850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

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
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Based on observation, interview , and record review, the licensee did not comply with the section cited above as the facility failed to conduct daily COVID-19 screening for residents and staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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Administrator will educate Staff on conducting daily screening for staff and residents. Administrator will monitor routinely to ensure it is done. Administrator will provide a copy of the education sign-in record to CCL by 8/15/2022. Administrator will provide a copy of the completed daily screening documentation for staff and residents from 8/3/2022 to 8/14/22 to CCL by 8/15/22.
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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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