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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202655
Report Date: 08/09/2024
Date Signed: 08/09/2024 04:40:01 PM


Document Has Been Signed on 08/09/2024 04:40 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: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: 14DATE:
08/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Josephine YongTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on the Type A and Type B deficiencies assessed during visit 7/24/2024. LPA Rai met with Administrator (ADM) Josephine Yong and stated the purpose of today's visit.

LPA Rai received the Plan of Corrections (POCs) in a timely manner. ADM provided R1's physician's order for medications which are being administered to resident at the facility. ADM provided in-service training to staff regarding medication administrator on 8/3/2024. ADM conducted disaster drill on 7/31/2024. Hospice agency provided foley catheter training to ADM and facility staff on 7/31/2024. ADM provided written order for resident using half-bed rails for mobility and placed in resident's file. ADM provided training for staff on resident's personal rights on 7/29/2024 and completion of training was in staff's file. ADM provided letter understanding laws and regulations, such as Title 22 and Health and Safety Code.

During visit, LPA Rai observed the electrical outlet was covered and the tile in the bathroom floor was repaired. LPA Rai observed the kitchen door was unlocked and open during duration of visit. LPA Rai observed written order from resident's physician's for using half-bed rail for mobility in 3 resident files.

During visit, LPA Rai cleared all Type A and Type B deficiencies and provided Letter of Deficiency Citations Cleared.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM) Josephine Yong and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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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