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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600211
Report Date: 06/28/2021
Date Signed: 06/28/2021 01:49:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:FELY-MAR ELDERLY CARE HOMEFACILITY NUMBER:
075600211
ADMINISTRATOR:MARIANO, FELINORFACILITY TYPE:
740
ADDRESS:2268 HIGHLANDS ROADTELEPHONE:
(510) 724-3248
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:5CENSUS: 3DATE:
06/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Licensee Felinor MarianoTIME COMPLETED:
02:00 PM
NARRATIVE
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On 06/28/2021 at approximately 9:20am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to the facility for another matter. LPA met with Licesee Feilnor Mariano.

LPA interviewed one licensee, three residents, and one staff. Licensee stated kitchen wall was removed. LPA does not have an updated facility sketch on file. Resident (R1) was not provided breakfast until 10:30am and Resident (R2) was not provided breakfast until 11:00am. LPA reviewed facility roster and Staff (S1) is working at the facility and has fingerprint clearance, but is not associated to the facility.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2021
Section Cited

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87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by: Based on interview and record review the
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licensee did not comply with the section cited above. Licensee stated wall was removed in kitchen and LPA does not have an updated facility sketch on file which poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/05/2021
Section Cited

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87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state
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licensed facility. This requirement was not met as evidence by: Based on interview and record review, the licensee did not comply with the section cited above. LLPA reviewed facility roster and Staff (S1) is working at the facility and has fingerprint clearance, but is not associated to the facility.which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2021
Section Cited

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87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food
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and Nutrition Board of the National Research Council... This requirement was not met as evidenced by: Based on obeservation and interview the licensee did not comply with the section cited above. Resident (R1) was not provided breakfast until 10:30am and Resident (R2) was not provided breakfast until 11:00am which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3