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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601159
Report Date: 09/06/2023
Date Signed: 09/06/2023 10:49:24 AM

Document Has Been Signed on 09/06/2023 10:49 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MARIAH'S GARDEN HOME CARE 2FACILITY NUMBER:
415601159
ADMINISTRATOR:ZEPEDA, MARIAFACILITY TYPE:
740
ADDRESS:195 CASTILLEJO DRIVETELEPHONE:
(650) 797-7951
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 0DATE:
09/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Maria ZepedaTIME COMPLETED:
11:00 AM
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On September 6, 2023 Licensing Program Analyst (LPA), Murial Han met with the Administrator, Maria Zepeda to conduct a pre-licensing inspection.

LPA observed the indoor and the outdoor passageways are free of obstruction.

Administrator provided a tour of the facility.

This is a single level facility. There is no residents during the time of the inspection, however, the staff room is being occupied by administrator's relative. LPA observed good lighting thought-out the facility but the temperature is measured at 61 degrees (F). LPA observed comfortable and appropriately furnished area in the living for residents and their family to gather.

LPA observed sufficient hygiene and cleaning supplies. Trash cans in the kitchen have tight fitting, and foot operated lids. LPA observed sufficient amount of non-perishable food, emergency food supplies, utensils, cooking wares and cleaning supplies. The first aid kit was inspected to be adequate.

LPA observed postings including CCL complaint poster, resident's rights, resident council rights, facility theft and lost program. However missing the LTC Ombudsman poster.

The facility is clean and tidy. There are 4 bedrooms( 3 shared resident rooms and 1 staff room). LPA observed room 3 did not have beds, furniture and the sliding door for the wall closet was detached from the track.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MARIAH'S GARDEN HOME CARE 2
FACILITY NUMBER: 415601159
VISIT DATE: 09/06/2023
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The water temperature in bathroom #1 located next to room #1 was measured at 104 degrees Fahrenheit (F) and LPA was not able to measure the water temperature in bathroom #2 located next to the staff room as the faucet was broken.

LPA observed laundry supplies and equipment to be adequate.

Pre-Licensing is incomplete during this inspection due to the following area of concerns:

- Fire place is observed not having a cover
- Facility has a balcony that residents can utilize for outdoor activities, however, the only way for residents to access it is by going through the staff room which may restrict resident from going outside.
- Room 3 did not have beds, furniture and the wall sliding door was not in good repair.
- Facility temperature was measured at 61 degrees F.
- Faucet in bathroom #2 is broken.

The administrator acknowledged the above observations.

A follow-up pre-licensing inspection will be scheduled.

Exit interview conducted with administrator,

A copy of this report is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC809 (FAS) - (06/04)
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