<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200696
Report Date: 10/02/2024
Date Signed: 10/02/2024 04:52:56 PM

Document Has Been Signed on 10/02/2024 04:52 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: 22DATE:
10/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Margie VillanuevaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Administrator (ADM) Margie Villanueva. The purpose of the visit was to both follow up with the fire that occurred at the facility on 07/16/2024 and an Incident Report submitted to the Department on 09/27/2024 reporting that resident R1 attempted to commit suicide at the facility by consuming a bottle that contained a mixture of water and bleach.

During visit, LPA observed the outdoor area and observed the backyard fence to be fully repaired. LPA observed chairs and tables in the outdoor area. LPA took photographs of the fence and backyard smoking area. LPA observed the tables had ashtrays on them. LPA recommended during visit for ADM to purchase cigarette collector receptacle containers and place them in the backyard smoking area.

LPA Marrufo interviewed ADM about R1's attempt to commit suicide at the facility on 09/25/2024. ADM stated that R1 approached ADM's spouse, who is also a Licensee of the facility, and handed a bottle to ADM's spouse. ADM stated R1 asked ADM's spouse to smell what was inside the bottle and then tried to forcibly take the bottle back and tried to drink it. ADM stated ADM's spouse was trying to prevent R1 from consuming the contents of the bottle by trying to take the bottle from R1's hands. ADM stated ADM's spouse called 911 for R1. ADM stated the bottle had a mixture of water and bleach. ADM stated R1 was sent to the hospital and is currently at a crisis residential facility.

ADM stated that the day prior to R1's suicide attempt, R1 had requested bleach from ADM to wash R1's sink. ADM provided R1 with a small spray bottle filled with mostly water and some bleach. ADM stated that the bottle ADM provided to R1 was the same bottle R1 tried to drink from when R1 attempted suicide. LPA Marrufo took a photograph of the bottle that ADM stated to have provided to R1. An Advisory Note was issued. See LIC9102 for more information. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information. This report was reviewed with ADM 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: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/02/2024 04:52 PM - It Cannot Be Edited


Created By: David Marrufo On 10/02/2024 at 04:38 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: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2024
Section Cited
CCR
80078(a)

1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision 80087(a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 was provided with care and supervision when the Licensee
1
2
3
4
5
6
7
Licensee agrees to develop a plan of correction by POC date to CCL to ensure that residents are supervised when handling bleach, cleaning solutions, and any other items that could pose a danger to residents.
8
9
10
11
12
13
14
provided R1 with a bottle containing bleach, which R1 later tried to consume in a suicide attempt.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2