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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200696
Report Date: 02/20/2025
Date Signed: 03/03/2025 01:18:03 PM

Document Has Been Signed on 03/03/2025 01:18 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: 28DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Margie VillanuevaTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Administrators Adoraim and Margie Villanueva.

During visit, LPA toured the facility inside and out.

LPA toured the kitchen area and observed there to be locked drawers for sharp objects and cleaning supplies. LPA Marrufo observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA reviewed the first aid kit and found it to be complete.

LPA toured 22 out of 22 resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA toured the bathroom in each bedroom and observed each bathroom to have working lights and available soap and paper towels. The water temperatures from the bathroom sinks on the first floor measured from 132 F to 135 F and the bathroom sinks on the second floor measured from 94 F to 104 F. During visit, Administrator Adoraim Villanueva tested the centralized smoke detector system and LPA observed the smoke detector system to function properly. LPA tested the carbon monoxide detector on the first floor and the carbon monoxide detector on the second floor and both functioned properly when tested.

LPA toured the outside area and found the outdoor exit to be clear of obstructions. LPA reviewed the Personal and Incidental Logs, the Centrally Stored Medication and Destruction Records, and the resident records for five residents and found them all to be complete. LPA reviewed five staff records and found them to be complete. The last recorded fire drill was conducted on 08/28/2024.

A deficiency was cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Margie Villanueva and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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Document Has Been Signed on 03/03/2025 01:18 PM - It Cannot Be Edited


Created By: David Marrufo On 02/20/2025 at 03:31 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, 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 four out of four bathroom sinks which measured between 94 F to 135 F, which poses an immediate safety risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Licensee agrees to submit a Plan of Correction by POC date stating how the water temperatures in the resident bathrooms will be kept between 105 F to 120 F. Once the water temperature is properly adjusted, Licensee shall submit video evidence showing water temperature in the resident bathrooms in both floors between 105 F to 120 F.
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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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