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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600988
Report Date: 12/09/2021
Date Signed: 12/09/2021 04:45:09 PM

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:MARIAH'S GARDEN HOME CAREFACILITY NUMBER:
415600988
ADMINISTRATOR:ZEPEDA, MARIE DFACILITY TYPE:
740
ADDRESS:1910 CRESTWOOD DRIVETELEPHONE:
(650) 307-7925
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Marie ZepedaTIME COMPLETED:
12:00 PM
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On 12/9/2021, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Administrator, Marie Zepeda. LPA explained the purpose of the visit.

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 (LPA recommended to document the temperature that was taken for the staff instead of check mark), containment strategies. there are 5 residents at the facility (2 females and 3 males). PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, hand washing instruction is posted by the hand washing stations. Trash cans are recommended to have foot operated lids. The beds in the shared bedrooms are 6"ft apart from each other.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

During today's inspection, LPA Han requested for the following documents to be submitted to the Regional Office by 12/14/2021:
- LIC 610E Updated Emergency Disaster Plan
- Lease Agreement
- LIC 308 Designation of Administrative Responsibility

No deficiency cited today; this report is reviewed and discussed with the Administrator. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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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