496803896-3-19-2024-21-AS-CCOO-D3HR4L-20240319124142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803896
Report Date: 03/19/2024
Date Signed: 03/19/2024 12:41:51 PM

Document Has Been Signed on 03/19/2024 12:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	MARIAN GARDENS CARE HOME - RCFE		FACILITY NUMBER:	496803896
ADMINISTRATOR:	DICHOSO, RAYMOND C.		FACILITY TYPE:	740
ADDRESS:	4908 STONEHEDGE DR		TELEPHONE:	(707) 791-3141
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 6	DATE:	03/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Raymond Dichoso, Administrator		TIME COMPLETED:	12:56 PM

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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Raymond Dichoso. Facility contact information was reviewed.

At approximately 9:15am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 110.3 and 109.8 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 4/24/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted with each staff member during their respective training days, LPA observed all training dates for respective staff were within the quarter. Facility has a backup generator for use during a power outage.

At approximately 10:30am LPA conducted a review of 6 resident records. All required documentation present. 1/2 rails and crushed meds orders all on file for respective residents. At approximately 11:30am LPA conducted review of 5 staff records. All required documentation present.

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies.

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SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MARIAN GARDENS CARE HOME - RCFE	FACILITY NUMBER: 496803896
	VISIT DATE: 03/19/2024

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Raymond Dichoso Administrator Certificate 6018339740 expired 8/31/2024. All fees are current as of this time.

LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
Current Lease

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

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