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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600850
Report Date: 09/21/2022
Date Signed: 09/21/2022 11:21:31 AM


Document Has Been Signed on 09/21/2022 11:21 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:MARINOL SENIOR CARE IFACILITY NUMBER:
415600850
ADMINISTRATOR:NANCY UYFACILITY TYPE:
740
ADDRESS:768 LUNDY WAYTELEPHONE:
(650) 557-1227
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY:6CENSUS: 5DATE:
09/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caregiver, Rizalina Alfafara TIME COMPLETED:
11:30 AM
NARRATIVE
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On 9/21/22, Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220627144305. LPA met with caregiver, Rizalina Alfafara and explained the purpose of the visit.

During the course of the investigation of allegation- facility did not provide residents with admission agreement, LPA reviewed the admission agreements for resident #1 (R1) and resident #2 (R2) and observed R1's admission packet was incomplete and not signed; R2's admission agreement was signed, however, it was incomplete.

Based on the complaint investigation, the facility did not ensure the admission agreements were signed and dated, acknowledging the contents of the documents, by the resident or the resident's representative. This deficiency will be cited on LIC809D.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with the caregiver.

A copy of this report and the Appeal Rights are provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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 09/21/2022 11:21 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
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: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2022
Section Cited

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87507 Admission Agreements..(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative,....
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This requirement was not met as evidenced by R1's admission agreement was incomplete and it was not signed by R1 and/or the responsible party. R2's admission agreement was incomplete which posed a potential health and safety risks to persons 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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
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