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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600987
Report Date: 10/08/2023
Date Signed: 10/11/2023 09:43:44 AM

Document Has Been Signed on 10/11/2023 09:43 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MARINA'S HOMEFACILITY NUMBER:
415600987
ADMINISTRATOR:BALDOZA, MARINAFACILITY TYPE:
740
ADDRESS:1424 SANCHEZ AVETELEPHONE:
(650) 375-1150
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 5DATE:
10/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marina BaldozaTIME COMPLETED:
03:20 PM
NARRATIVE
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REPORT AMENDED TO RESCIND DEFICIENCY AND CIVIL PENALTY. LPA met with Gary Baldoza during this visit.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/8/23 at 10:00AM. LPA met with Caregivers Ermenia Pascual Domingo and Andres De La Cruz Bayang who contacted the Administrator Marina Baldoza regarding the purpose of todays visit. Marina Baldoza arrived at 12:00pm to assist with todays visit. The Administrator Certificate was observed for Marina Baldoza which expires 8/16/24.

LPA observed a receipt that indicates on 9/28/23, the Licensing fees were paid in the amount of $495.00.

The facility is licensed for a capacity of 6 non-ambulatory residents of which 2 may receive hospice care services. There are 0 residents receiving hospice services at this time. LPA was provided a copy of the approved, signed, hospice waiver for 2 during this visit.

LPA observed residents and conversed with them during this visit.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 117.1*F which is within the required range of 105-120*F.

LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 3 staff and 2 resident files and conducted interviews during this visit. LPA did not observe a first aid/CPR certificate for the 3 staff during this visit.
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2023
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 10/11/2023 09:43 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/09/2023 03:55 PM


Created By: Victoria Brown On 10/08/2023 at 01:10 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARINA'S HOME
FACILITY NUMBER: 415600987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2023
Section Cited

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Personnel Requirements - General

Deficiency and Civil Penalty RESCINDED
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Deficiency and Civil Penalty RESCINDED
Type A
10/09/2023
Section Cited

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Personnel Requirements - General
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69...
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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This requirement is not met as evidenced by: LPA did not observe first aid/CPR certificates for that caregivers 1 & 2 nor the Administrator. Based on: LPA observed expired certificates during file review. This violation poses an immediate health, and safety risk to residents in care.
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 Training scheduled for 10/16/2023 for 4 staff.

Plan of Correction cleared during todays visit.
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:Victoria Brown
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2023


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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MARINA'S HOME
FACILITY NUMBER: 415600987
VISIT DATE: 10/08/2023
NARRATIVE
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LPA observed the following that shall be cited during this visit.

LPA observed that the 2 caregivers are not associated to the facility on LIS system nor the Guardian system during this visit. Administrator provided a copy of a roster with the 2 staff hand written dated 7/12/23, however, there is no proof that the document was submitted to Community Care Licensing (CCL) and administrator did not follow-up to ensure the staff were associated to the facility. Administrator was provided a copy of the guardian roster as well that did not contain the 2 staff names.

DEFICIENCY AND CIVIL PENALTY RESCINDED. PROOF WAS PROVIDED THAT CAREGIVERS WERE INADVERTENTLY REMOVED BY COMMUNITY CARE LICENSING (CCL) SYSTEM. LPA OBSERVED A LIS ROSTER DATED 5/29/2020 THAT INCLUDES BOTH CAREGIVER NAMES THAT LICENSEE DID NOT REQUEST TO BE REMOVED.

Upon a file review the following items were discussed to be submitted with any changes annually:
LPA and Administrator reviewed the Infection Control Plan which is to be completed and submitted to Community Care Licensing (CCL), Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610E), Plan for incidental and Medical and Dental Care, Liability Insurance, Control of Property, Health Screening with TB for all staff.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. You are hereby assessed an immediate civil penalty is being assessed in the amount of $200 during this visit.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2023
LIC809 (FAS) - (06/04)
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