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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202052
Report Date: 02/28/2022
Date Signed: 02/28/2022 04:35:28 PM


Document Has Been Signed on 02/28/2022 04:35 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MARILAG'S CARE HOMEFACILITY NUMBER:
435202052
ADMINISTRATOR:WENNIE R. CONCEPCIONFACILITY TYPE:
740
ADDRESS:2293 LANAI AVE.TELEPHONE:
(408) 272-3155
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:6CENSUS: 3DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:WENNIE R. CONCEPCIONTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with administrator (ADM) Wennice Concepcion. Upon arrival, staff Ana Guaco (S1) took LPA body temperature and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. COVID posters 3923were observed at the main entrance and in facility. 3 residents were observed in facility.

LPA toured the facility inside out with ADM. LPA inspected living room, kitchen, dinning area, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked. There are 3 resident rooms, three staff live-in rooms, and three restrooms in facility. Paper towels were observed without holders, ADM replaced all paper towels with holders. Cloth towels were observed in kitchen. ADM removed the cloth towel in kitchen. Trash cans were observed with covers. Washing hands signs were observed by the sinks in restrooms and kitchen. Room temperature was observed at 73 degree F, and hot water temperature was observed at 105 degree F. 2 days perishable food supplies and 7 days nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the smoke and carbon monoxide detectors, and they were working fine. LPA inspected the backyard, there was no obstruction to block the walkway. ADM stated all staff and residents are fully vaccinated and done with booster.

No deficiency or issue noted during inspection. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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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