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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803938
Report Date: 01/21/2021
Date Signed: 01/21/2021 04:16:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GARDENVIEW OF MARIAN HOMEFACILITY NUMBER:
496803938
ADMINISTRATOR:SUMABAT, SHEILAFACILITY TYPE:
740
ADDRESS:2319 BISMARK COURTTELEPHONE:
(707) 536-5738
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 6DATE:
01/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Sheila Sumabat, ApplicantTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Mota spoke with Applicant, Sheila Sumabat, this date virtually. The purpose of this tele-visit is a pre-licensing inspection. The inspection is being conducted by Facetime due to COVID - 19 precautions. The reader is advised that the LPA did not physically make a site visit.
Comp 3 Review:
LPA discussed with Regional Manager, Carla Martinez who approved the waiving of this requirement based on applicant's knowledge. Facility is/has been in compliance and inspection is being conducted due to a name change with the same operator.
Tour/Inspection:
The facility has 5 bedrooms and 3 and 1/2 baths and a large fenced back yard where residents were observed sitting on the deck while social distancing. The grounds were free of any apparent hazards, fire exits clear. Patio area comfortably furnished. The interior was clean and adequately furnished. Smoke; fire; carbon monoxide all current. Santa Rosa Fire Department cleared the facility on 10/26/20 for 6 non ambulatory residents. No bodies of water. No firearms. Locked cabinets for resident and staff records, as well as medications, observed in the office. Kitchen was spacious and clean, adequate supply of dishes and utensils, locked drawer for sharps. Food appeared adequate and safe for 6 residents in care. Postings noted to be current and in compliance with regulations. Locked cabinets for cleaning/laundry supplies in garage. First aid kits are located in the medicine cabinet as well as in the disaster bin kept in the garage along with "Go Kits" in the event of an emergency. Resident bedrooms clean and adequately furnished; ample linens. COVID-19 postings were observed at the front door and throughout the facility including bathrooms. Screening area was observed where temperatures and symptoms are taken and logged.
Copy of report to be scanned/emailed to Applicant for signature and will be final printed upon receipt.

Pre-Licensing is complete and this facility has no apparent deficiencies.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Kimberley MotaTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021
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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