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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600988
Report Date: 08/14/2024
Date Signed: 08/14/2024 05:24:51 PM

Document Has Been Signed on 08/14/2024 05:24 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:MARIAH'S GARDEN HOME CAREFACILITY NUMBER:
415600988
ADMINISTRATOR/
DIRECTOR:		ZEPEDA, MARIE DFACILITY TYPE:
740
ADDRESS:1910 CRESTWOOD DRIVETELEPHONE:
(650) 307-7925
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 5DATE:
08/14/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Administrator, Maria ZepedaTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On August 14, 2024, Licensing Program Analysts (LPAs) Murial Han arrived unannounced to conduct an annual continuation for an annual required inspection conducted on August 7, 2024. LPA met with administrator, Maria Zepeda and LPA explained the purpose of the visit.

During today's visit, LPAs toured the facility, reviewed resident records and emergency drills.

No deficiencies cited today.

This report is reviewed and discussed with the administrator.

A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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