<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600988
Report Date: 08/14/2024
Date Signed: 08/14/2024 10:19:01 AM


Document Has Been Signed on 08/14/2024 10:19 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: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:
08/14/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Maria ZepedaTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On August 14, 2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced Plan Of Correction visit. LPA met with the administrator and explained the purpose of today's visit.

During the visit, LPA toured the facility, observed medications, chemicals, sharps, and disinfectants are locked and inaccessible to residents in care.

LPA observed the kitchen, living room, bathroom and resident rooms are cleaned and tidy. LPA observed the environment is comfortable.

The following deficiencies are cleared:

87303(a)- 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.

87309(a)- (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

87555(b)(25)- (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.

87555(b)(27)- (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

80075(k)(1)- 80075 Health Related Services

No deficiency is cited today.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
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)
Page: 1 of 1