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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600987
Report Date: 09/03/2024
Date Signed: 09/03/2024 06:18:05 PM

Document Has Been Signed on 09/03/2024 06:18 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:MARINA'S HOMEFACILITY NUMBER:
415600987
ADMINISTRATOR/
DIRECTOR:		BALDOZA, MARINAFACILITY TYPE:
740
ADDRESS:1424 SANCHEZ AVETELEPHONE:
(650) 375-1150
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 5DATE:
09/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver, Ermenia DomingoTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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On September 3, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Ermenia Domingo and explained the purpose of today's visit. Caregiver, Gary Baldoza arrived during the inspection.

LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. This is a 6 bed facility with 2 private rooms, 2 shared rooms and 2.5 bathrooms. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort.

Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.

LPA observed chemicals underneath the kitchen sink was not locked and accessible to residents in care.

Central storage for medication was observed to be locked and inaccessible to residents in care.

Hot water temperature in the kitchen and bathroom were measured at 107-110 degrees Fahrenheit.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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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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: 09/03/2024
NARRATIVE
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LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

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

This report is reviewed and discussed with the caregiver. A copy of this report and the appeal rights were provided
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/03/2024 06:18 PM - It Cannot Be Edited


Created By: Murial Han On 09/03/2024 at 11:29 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: MARINA'S HOME
FACILITY NUMBER: 415600987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)


This requirement is not met as evidenced by:87506 Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident...
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 5 out of 5 residents appraisal needs and service plans are either missing resident or responsible party's signature(s) and/or the facility representative signature which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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The administrator will provide a copy of the completed appraisal needs and service plans for all the residents to CCL by 9/9/2024.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2024 06:18 PM - It Cannot Be Edited


Created By: Murial Han On 09/03/2024 at 11:40 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: MARINA'S HOME
FACILITY NUMBER: 415600987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed chemicals underneath the kitchen sink was not locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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The administrator will develop a plan to ensure chemicals are locked at all times and will provide a photo to proof that all chemicals are locked. The administrator will provide a copy of the plan and photo to CCL by 9/4/2024.
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 2 staff did not complete their annual training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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The administrator will develop a plan to prevent this from happening again and on the plan, it shall indicate when the training will be completed for the 2 facility staff and the completion date shall not exceed 9/6/2024. The administrator will provide a copy of the plan to CCL by 9/4/2024 and will provide a copy of the training records to CCL by 9/9/2024.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/03/2024 06:18 PM - It Cannot Be Edited


Created By: Murial Han On 09/03/2024 at 11:40 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: MARINA'S HOME
FACILITY NUMBER: 415600987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility did not have any training records to ensure the emergency drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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The administrator will develop a plan to ensure emergency drills are conducted accordingly and in the plan, it shall indicate when a drill will be conducted and the date shall be no later than 9/6/2024. The administrator will provide a copy of the plan to CCL by 9/4/2024 and a copy of the emergency drill training record to CCL by 9/9/2024.
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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 resident has bedrails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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The administrator will provide a copy of the physician's order for the bedrails to CCL by 9/4/2024.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/03/2024 06:18 PM - It Cannot Be Edited


Created By: Murial Han On 09/03/2024 at 11:40 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: MARINA'S HOME
FACILITY NUMBER: 415600987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 2 staff personnel files are missing documents such as the CPR& First Aid Training Certificates, training records, etc, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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The administrator will develop a plan to ensure personnel records are maintained at all times and will provide a copy of the plan to CCL by 9/9/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
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