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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601159
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:09:32 PM

Document Has Been Signed on 09/17/2024 02:09 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:
09/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Maria Zepeda, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On September 17, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra conducted an unannounced case-management visit. On 9/17/2024, LPAs conducted a plan of correction (POC) visit to follow up on an deficiency that was cited during an annual visit on 9/10/2024. LPAs met with staff member (S1), Alejandro Ortiz and explained the purpose of the visit. Administrator, Maria Zepeda joined shortly thereafter.

During the visit, LPAs observed S1 to not be fingerprints cleared and/or associated to the facility. Administrator provided fingerprint clearance for S1, however she did not associate them to the facility.

Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator and a copy of this report and the Appeal Rights is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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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Document Has Been Signed on 09/17/2024 02:09 PM - It Cannot Be Edited


Created By: Kiran Jain On 09/17/2024 at 01:53 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: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or...

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator shall submit S1's LIC9182 to CCL by 9/17/2024.
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Licensee/Administrator failed to associate S1 to the facility prior to working.
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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: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
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