496803231-2-27-2024-21-AS-DALO-D2V2N5-20240227163211

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803231
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:32:19 PM

Document Has Been Signed on 02/27/2024 04:32 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	MARIAN HOUSE FOR SENIORS		FACILITY NUMBER:	496803231
ADMINISTRATOR:	SUMABAT, RAMON & SHEILA		FACILITY TYPE:	740
ADDRESS:	2043 GUERNEVILLE ROAD		TELEPHONE:	(707) 843-7087
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 5	DATE:	02/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Rosie Achacon-Lead Caregiver		TIME COMPLETED:	04:45 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) Alviso, conducted a Required 1 -Year Inspection, 2/27/24 at approximately 1:15pm, and met with Lead caregiver Rosie (Rosario) Achacon. LPA observed another caregiver, Fely Delapena, on duty. Caregiver Rosie contacted the Licensee/Administrator Sheila Sumabat to notify them of the LPA's arrival to the facility. Administrator Sheila arrived within 20 minutes of being contacted. There are five (5) residents in care. The facility has a required infection control plan. The facility has a required emergency & disaster plan. Facility has an approved dementia plan of operation. There is an approved hospice waiver for four (4) residents. Fire clearance is approved for six (6) non-ambulatory. Fire extinguisher is serviced and tagged as required, expires 8/17/24. Facility has smoke alarms as required, and a carbon monoxide detector as required. Per review of records, fire/emergency drills are held quarterly as required: Last drill conducted was a fire and evacuation drill, held on 1/2/24. The facility held a fire, and earthquake drill 10/20/23, and three other emergency drills in the year 2023. The LPA toured the facility with caregiver Rosie. Hot water was checked at 113.2 degrees Fahrenheit. Medications were locked up as required. Cleaners/toxins were locked up as required. All exits and walkways were clear, and unobstructed as required. LPA observed there was sufficient lighting in hallways, bathrooms, common areas, and resident rooms. Facility was observed to be at a comfortable temperature. Facility was observed to clean and orderly. Food supply was sufficient. Facility had emergency supplies stored to meet the "72 hours in place" requirement. `Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MARIAN HOUSE FOR SENIORS	FACILITY NUMBER: 496803231
	VISIT DATE: 02/27/2024

NARRATIVE

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Facility had a sufficient supply of linens, and furnishings for resident use. There is an outside patio area, with table, umbrella, and chairs for resident use. All resident bathrooms had grab bars as required. Resident shower room has grab bars, and shower mat for resident use.

The LPA reviewed five (5) resident files. All files were complete.

LPA reviewed five (5) staff files. LPA reviewed staff training. All five(5) staff have criminal record clearance as required. All staff are associated as required. All staff had required annual training. All staff had current First Aid and CPR Certification.

LPA is requesting the following documents be updated and submitted by 3/27/24:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan- review and submit (provide all information in all boxes as required)
Infection Control Plan- review and submit (provide all information as required)
Copy of LIC400 Handling of Client Cash Resources (complete the form even if not handling cash)
Copy of required Surety Bond (if handling cash)
Copy of Current required Liability Insurance
Copy of current Administrator Certificate

There were no deficiencies cited today.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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