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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200696
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:28:13 PM

Document Has Been Signed on 07/16/2024 03:28 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/
DIRECTOR:		ADORAIM VILLANUEVAFACILITY TYPE:
735
ADDRESS:443 SOUTH 11TH STREETTELEPHONE:
(408) 279-9892
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 34CENSUS: 26DATE:
07/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Margie VillanuevaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Margie Villanueva. The purpose of the visit was to respond to report of a fire at the facility that the facility reported by telephone call to the Desk Duty Officer of the Day on 07/16/2023.

During visit, LPA Marrufo spoke with Administrator (ADM) Margie Villanueva. ADM stated that around 1:20 AM on 07/16/2024, a resident from an upper floor room observed a fire in the backyard smoking area and witnessed another resident in the smoking area at the same time. ADM stated that the resident in the upper floor room called 911. ADM stated that she and Administrator Adoraim Villanueva pulled the emergency fire alarm, which functioned properly at that time. Then, both Administrators evacuated 100% of the residents from the facility to the front yard area. ADM stated by 2:00 AM, the fire department had extinguished the fire. ADM stated that the fire department conducted an investigation and will be able to provide a report within 7 calendar days. ADM stated that the fire department advised ADM not to touch or alter anything in the area that the fire damaged. LPA observed police tape around the damaged area during visit. The damaged area included part of the backyard area that was designated as a smoking area as well as the rear and side fences of the facility. LPA Marrufo took photographs of the damaged area during visit. LPA toured 17 out of 17 resident bedrooms and found the doorway to one of the bedrooms that is closest to the rear entrance was damaged.

LPA Marrufo requests that ADM provided an action plan as to what the ADM will do with the damaged area of the facility and submit it to the Department by 07/23/2024. ADM stated during visit that ADM will have the damaged doorway fixed today. No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with ADM Margie Villanueva and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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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