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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803938
Report Date: 01/23/2024
Date Signed: 01/23/2024 03:12:44 PM


Document Has Been Signed on 01/23/2024 03:12 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: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:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Sheila Sumabat, AdministratorTIME COMPLETED:
03:27 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. LPA had computer issues upon trying to open FAS. Sheila Sumabat, Administrator arrived later. Facility currently has 1 resident on hospice which is allowable per the facility's Hospice Waiver. Facility contact information was reviewed.

At approximately 9:00am LPA 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 and labeled. Kitchen cabinet containing cleaning supplies was locked. Additional cleaning and laundry supplies located in staff room in locked cabinet.



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 bathrooms had required bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 108.7 and 106.2 degrees F, respectively, which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 9/29/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 1/3/2024. Facility has two backup generators for use during a power outage.

At approximately 12:00pm LPA conducted a review of six [6] out of six [6] resident and five [5] staff records. Per LPA record review, resident (R1) is bedridden per most recent LIC602 and Admin verification. R1 was not bedridden when admitted to facility 9/2022. R1 was placed on hospice beginning 10/2022 and was considered bedridden 01/2023. LPA and Admin verified with Santa Rosa Fire Dept that the most current STD850 for the facility dated 2020.

Report continued on LIC 809-C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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: GARDENVIEW OF MARIAN HOME
FACILITY NUMBER: 496803938
VISIT DATE: 01/23/2024
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Continued from 809...

Current STD850 dated 2020 grants fire clearance for 6 non-ambulatory. Facility to submit updated facility sketch showing Room #6 as a bedridden bedroom to CCL within 5 business days of today, January 23, 2024. CCL to follow-up once updated facility sketch received.

At approximately 2:00pm LPA, Admin, and Caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked filing cabinet in the staff room. Medications stored in labeled bins, for each respective resident. Door from kitchen leading to staff room has keypad lock.

Sheila Sumabat Administrator Certificate # 6022683740 expires 12/20/2024. All fees are current as of this time. LPA gave LIS printout showing PIN for online payment.

LPA and Admin discussed facility's Infection Control Plan and Emergency disaster plan. Both are current, no updates needed.

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
Evidence of Liability Insurance

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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