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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202655
Report Date: 06/08/2021
Date Signed: 07/21/2021 09:20:23 AM

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:MARQUEZ LIVING I (RCFE)FACILITY NUMBER:
435202655
ADMINISTRATOR:MARQUEZ LORENZO, MARIAFACILITY TYPE:
740
ADDRESS:994 SOBRATO DRTELEPHONE:
(408) 533-2829
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:14CENSUS: 13DATE:
06/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Maria MarquezTIME COMPLETED:
12:07 PM
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Licensing Program Analyst Ryker Heberle (LPA) and Licensing Program Manager Sarah Yip (LPM) conducted an unannounced annual inspection on 06/08/2021 at 9:34am. LPA and LPM met with facility administrator Maria Marquez (Admin).

LPAs toured the facility, including front hall way, living room, all resident rooms, all bathrooms, kitchen, dining room, back and side patios, laundry room, storage room, and all staff rooms.

All staff members observed to be wearing masks. No residents in facility observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated. Facility observed to have adequate supply of PPE.

Facility observed to have designated entry point. Staff took LPA and LPM's temperature, but did not screen for symptoms. Facility does not have a written symptom screening questionnaire. All restrooms observed to be adequately stocked with paper towels, hand sanitizer, and hand soap. Hand washing signs observed in bathrooms. Social distancing signs observed posted throughout facility. Bathrooms observed to not have lidded trash cans. LPA reminded Admin to create a symptom screening questionnaire to be filled out by all visitors and returning residents upon entry into the facility. LPA also reminded Admin to stock bathrooms with lidded trash cans operable via foot pedal or motion sensor.

LPA noted 2 residents had medication in their rooms. Upon review of resident records, 1 of the 2 residents was not allowed to store their own medication, but was capable of administering their own medication. 1 of 2 residents was allowed to store their own medication, but said resident's roommate was not. LPA advised Admin to store resident medications when resident is no longer using medication and to remind resident to store their medication out of sight upon completion of administration. LPA observed Admin store resident medications out of sight.

LPA observed 3 obstructed sliding glass door fire exits in resident rooms. LPA advised Admin to rearrange rooms to remove the obstructions. Main fire exits observed to be unobstructed.

LPA requested revised copy of 808 Mitigation Plan and LIC 500 to be submitted within 30 days.

Advisory notes issued, see LIC 9102.

This report reviewed with Administrator Maria Marquez and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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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