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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601159
Report Date: 06/05/2025
Date Signed: 06/05/2025 10:44:04 AM

Document Has Been Signed on 06/05/2025 10:44 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 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: 0DATE:
06/05/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Ismail ZepedaTIME VISIT/
INSPECTION COMPLETED:
10:54 AM
NARRATIVE
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On June 5, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management- facility closure visit. LPA met with Administrator, Ismail Zepeda and explained the purpose of the visit.

Licensee notified CCLD of facility closure on 4/18/25.

LPA toured the facility. Facility is two floors. Residents resided on the second floor. During the tour, LPA observed the kitchen, living room, dining room, bedrooms and garage. LPA did not observe any residents and did not observe evidence of care and supervision In the home.

CCLD will be proceeding with the closure. A forfeiture letter will be sent to licensee and the facility number 415601159 shall be closed.



This report is reviewed, and discussed with the Licensee, and a copy is provided.

Deficiencies are also delivered during the visit and cited from the California Code of Regulations, Title 22. See LIC809-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with administrator and copy of the report and appeals rights are provided.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Charitra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/05/2025 10:44 AM - It Cannot Be Edited


Created By: Komal Charitra On 06/05/2025 at 10:17 AM
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: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2025
Section Cited
CCR
87405(d)(2)

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87405 Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This regulation is not met as evidenced by:
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Licensee/administrator shall review regulations Administrator Qualifications 87405(d)(2) and Eviction Procedures 87224(c) and submit acknowledgement to LPA.
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Based on records review, the Licensee/administrator did not follow properly notify CCLD of facility closure and failed to submit a plan including but not limited to; timeframe, transferring of residents which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
06/06/2025
Section Cited
HSC1569.682(a)(2)

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1569.682 Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties: (a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility... as a result of the forfeiture of a license, as described in subdivision (a), (b), or (f) of Section 1569.19... pursuant to the department’s regulations, take all reasonable steps to transfer affected residents safely...shall, at a minimum, do all of the following... (2) Provide each resident or the resident's responsible person with a written notice no later than 60 days before the intended eviction. The notice shall include all of the following...

This regulation is not met as evidenced by:
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Licensee/administrator shall review Health and Safety code 1569.682 and submit acknowledgement to LPA.
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Based on interviews and records reviews, the facility failed to provide residents a 60- days notice that includes all of the following listed on Health and Safety Code, 1569.682(a)(2); (A)-(F)
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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