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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600988
Report Date: 08/07/2024
Date Signed: 08/07/2024 06:41:48 PM


Document Has Been Signed on 08/07/2024 06:41 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:ZEPEDA, MARIE DFACILITY TYPE:
740
ADDRESS:1910 CRESTWOOD DRIVETELEPHONE:
(650) 307-7925
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Caregiver, Maria Clementina Zepeda AreasTIME COMPLETED:
11:40 AM
NARRATIVE
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aOn August 7, 2024 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Maria Clementina Zepeda Areas and explained the purpose of today's visit. The administrator, Maria Zepeda arrived later and assisted with the inspection.

LPA toured the facility inside and outside including the bedrooms (3 shared bedrooms), 2 full- bathrooms, kitchen, living and dining rooms. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars and non-skid mat. Facility temperature is comfortable. Hot water temperature was measured at 105-106 degrees F.

During the tour, LPA observed stairs to the garage were dirty and sticky, sharps and chemicals were not locked in the kitchen, unknown brown/crumbs on the kitchen floor, medication cabinet has a lock with the key on it, fruit flies in the kitchen area, vegetables were placed on the kitchen floor, dirty dishes in the sink, resident room was not tidy with two dirty wheelchair wheels on the dresser, clothes hanging all over the place, unused mattress in one of the resident's room, the brown couch in the living room has soiled towels, an empty box, and the dining room table is messy and sticky with many stains and brown particles.

A total civil penalty of $750.00 is being assessed today for 3 repeat violation.

LPA is unable to complete the annual inspection today and will return on another day to complete it.

This report is reviewed and discussed with the administrator. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 08/07/2024 06:41 PM - 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MARIAH'S GARDEN HOME CARE
FACILITY NUMBER: 415600988

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 living room, resident's room, stairwell, kitchen and dining room was not cleaned which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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4
The administrator/licensee will develop a plan to ensure the facility is cleaned, safe, sanitary and in good repair at all times and will submit a copy of the plan to CCL by 8/8/2024. Civil Penalty is being assessed for repeat violation.
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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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed chemical, sharps and disinfectants were not locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 8/8/2024. Civil Penalty is being assessed for repeat violation.
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 CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 08/07/2024 06:41 PM - 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MARIAH'S GARDEN HOME CARE
FACILITY NUMBER: 415600988

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 a bottle of window cleaner placed next to a rack of vegetables and fruits which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure food safety is observed at all times and will provide a copy of the plan to CCL by 8/8/2024.
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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 fruit flies in the kitchen, the bathroom and the living room, coffee machine, garbage can, kitchen floor, etc to be dirty with sticky particles and brown crumbs which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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4
The adminstrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 8/8/2024. Civil Penalty is being assessed for repeat violation.
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 CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/07/2024 06:41 PM - 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MARIAH'S GARDEN HOME CARE
FACILITY NUMBER: 415600988

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)


This requirement is not met as evidenced by: 80075 Health Related Services
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 the medication cabinet has a lock on it with the key attached which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance and the plan shall include staff training. The administrator will provide a copy of the plan to CCL by 8/8/2024.
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 CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4