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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803938
Report Date: 07/27/2021
Date Signed: 07/27/2021 01:37:06 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) 521-9597
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 6DATE:
07/27/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Sheila SumabatTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos conducted an unannounced POST licensing inspection of this licensed senior care facility and was greeted by caregiver. Administrator was contacted and arrived a short time later. LPA toured the building and grounds which were found to be clean and in good repair. There are currently 6 resident in care. All walkways and exits were observed to be unobstructed.

The amount of fresh and nonperishable foods is within regulation. Toxins are stored under locked sinks and in locked laundry room, therefore inaccessible to residents in care. Medications are locked and stored in a cabinet, therefore inaccessible to residents. Water temperature measured at 116.0 and 115.8 degrees F which is within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguisher inspected was charged dated 9/9/2020. Smoke detectors were tested and found to be in working order. Carbon Monoxide detector was present and is part of the smoke detector system. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings. Exit alarms on exit doors were working properly.

LPA reviewed 1 resident and 1 staff record. All files contained required documentation and training records.

At primary entrance LPA observed temperature log and visitor sign in sheet. LPA observed COVID postings and hand sanitizer throughout facility. Community care licensing has received and reviewed facility's mitigation plan.

LPA requested current copy of Liability Insurance during visit.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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