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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601159
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:32:38 PM

Document Has Been Signed on 09/10/2024 02:32 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 CARE 2FACILITY NUMBER:
415601159
ADMINISTRATOR/
DIRECTOR:		ZEPEDA, MARIAFACILITY TYPE:
740
ADDRESS:195 CASTILLEJO DRIVETELEPHONE:
(650) 797-7951
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 4DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Maria Zepeda, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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On September 10, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra arrived at the facility at 11:45 AM to conduct the Annual 1-year required inspection. LPAs met with Elizabeth Romero and Hani Fadli, caregivers, and explained the purpose of the visit. Maria Zepeda, Licensee/Administrator and Ismail Zepeda, joined shortly thereafter.

LPAs toured the physical plant and observed it to be clean and odor free at a comfortable temperature. This is a two-story building with 2 shared resident bedrooms, 2 staff bedroom, 2 full bathrooms, a living room, and a kitchen with dining. No accessible bodies of water or hazards were observed. The fire extinguisher was fully charged and purchased on 09/19/2023. The smoke detector and carbon monoxide detector were fully operational.

The attached garage at the first floor was observed to have a washer and dryer for laundry and extra food supply storage. Back half of the garage was observed to be converted into living quarter for the staff members. LPAs observed 2 beds in the living quarter of the garage.

All rooms were observed to be clean with required furniture and sufficient lighting. The bathroom was observed to be mold-free and contained grab bars, bar soap, and non-skid mat. Toilet paper rolls and paper towels were not observed in the bathroom. According to the Administrator, residents have behavioral issues. The hot water temperature in the bathroom sink faucet was measured at 133.8°F. Administrator has Hot Water caution signs posted above each sink.

Sharp objects, detergents, poisons, and soap were observed to be accessible to persons in care. In the presence of the LPAs, they were locked and are no longer accessible to persons in care. No expired food items were observed. The facility had the required 7 days of non-perishables and 2 days of perishables.

LPAs reviewed four resident records and five staff records. All were observed to be complete.

Continued to 809-C...

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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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 2
FACILITY NUMBER: 415601159
VISIT DATE: 09/10/2024
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The resident’s medications are securely stored in a locked cabinet. Medication administration records (MARs) were reviewed, and no expired medications were observed. The First Aid kit was checked and observed to be completed.

The following updated forms are requested to be submitted to CCLD by 09/17/2024:


· LIC 500: Personnel Report
· Updated LIC 308: Designation of Facility Responsibility
· Updated LIC 400: Resident Cash Resources
· Updated First Aid Certificate
· Liability Insurance
· Current Lease Agreement

A Type A Violation was provided for the Garage used as a sleeping room for the staff members.

The deficiency is cited under the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

An exit interview was conducted. This report was reviewed with Maria Zepeda, Administrator, and a copy of this report along with appeal rights was left at the facility.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2024 02:32 PM - It Cannot Be Edited


Created By: Kiran Jain On 09/10/2024 at 02:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARIAH'S GARDEN HOME CARE 2
FACILITY NUMBER: 415601159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPAs observed 2 beds located on the left side of the garage which is being used as a sleeping area for a staff member, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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The Administrator/Licensee will remove the two beds from the garage and provide LPAs photos as proof of correction by the due date. In addition, Administartor/ licensee to submit a plan in writting regarding how facility will accomodate live-in staff moving forward.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


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