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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200696
Report Date: 02/12/2024
Date Signed: 02/12/2024 02:11:50 PM

Document Has Been Signed on 02/12/2024 02:11 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MARIAN HALLFACILITY NUMBER:
435200696
ADMINISTRATOR:ADORAIM VILLANUEVAFACILITY TYPE:
735
ADDRESS:443 SOUTH 11TH STREETTELEPHONE:
(408) 279-9892
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 34CENSUS: 29DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Margie VillanuevaTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Margie Villanueva.

During visit, LPA Marrufo toured the facility inside and out. The facility kitchen and food storage areas had a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured 17 out of 17 resident bedrooms and found each bedroom to have working lights and available bedding. The water temperatures in the sinks in Rooms 10, 12, 16, and 17 were 90 F, 88 F, 94 F, and 92 F respectively. Room 11 had a stereo tower and a 4 foot figurine in the hallway. The inside of Room 11 had piles of personal belongings that impeded movement within the bedroom.

Two out of two carbon monoxide detectors were tested and functioned properly when tested. Administrator Margie Villanueva showed LPA Marrufo an Alarm System inspection report from 01/19/2024 that stated all alarm systems were functioning properly.

The outdoor exits were toured and found to be clear of obstructions.

LPA Marrufo reviewed resident and staff records, Centrally Stored Medication logs, and Personal and Incidental Money Logs for 5 residents and 5 staff. All records were found to be complete.

Deficiencies were made as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Administrators Adoraim and Margie Villanueva and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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 02/12/2024 02:11 PM - It Cannot Be Edited


Created By: David Marrufo On 02/12/2024 at 01:43 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARIAN HALL
FACILITY NUMBER: 435200696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 17 resident bedrooms, which had hoarded belongings that were obstructing the movement within the bedroom, and 1 out of 11 bathrooms, which had a leaky sink pipe, which pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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Licensee agrees to submit a Plan of Correction by POC date describing how the licensee shall repair the leaky pipe in the bathroom of Room 3 and clean up the hoarded belongings in Room 11 that were obstructing movement with the bedroom and hallway. Once the leaky pipe is repaired and Room 11 and the hallway are clear of obstructions from hoarded belongings, the licensee shall submit photographic evidence to CCL.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of 11 bathrooms that had water temperature below 105 F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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Licensee agrees to submit a Plan of Correction by POC date describing how the licensee shall ensure that all resident bathroom water temperatures are between 105 F and 120 F.
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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
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