Community Care Licensing

Document Has Been Signed on 09/15/2023 04:12 PM - It Cannot Be Edited

FACILITY NAME:	MARSTON CORPORATION		FACILITY NUMBER:	079201176
ADMINISTRATOR:	UY, RONALD		FACILITY TYPE:	740
ADDRESS:	871 BRITTANY LANE		TELEPHONE:	(650) 255-9603
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY: 6		CENSUS: 3	DATE:	09/15/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Kristabelle Alatas, Corporate board member		TIME COMPLETED:	04:20 PM

SUPERVISORS NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023

Link to Parent Document Below:

FACILITY NAME: MARSTON CORPORATION	FACILITY NUMBER: 079201176
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/16/2023 Section Cited CCR 87309(a)	1 2 3 4 5 6 7	(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility will lock up knifes and sharpe objects. The facility will also collect all chemicals from each room and lock them in a centerally stored location. Proof of correction will be sent to CCLD by POC date.
	8 9 10 11 12 13 14	Knifes and chemical cleaners were observed unlocked in the garage, bathrooms, bedroom and kitchen	8 9 10 11 12 13 14
Type A 09/16/2023 Section Cited CCR87506(a)	1 2 3 4 5 6 7	The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility will complete the resident record Proof of correction will be sent to CCLD by POC date.
	8 9 10 11 12 13 14	The facility staff was putting together the one of the resident records after the LPA asked for it, and gave it saying that it was not complete yet.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023

Link to Parent Document Below:

FACILITY NAME: MARSTON CORPORATION	FACILITY NUMBER: 079201176
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/19/2023 Section Cited CCR 87355(e)2)	1 2 3 4 5 6 7	All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility:Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator will submit a transfer request form with current I.D. to associate S2 and S3 to the facility by due date.
	8 9 10 11 12 13 14	Two staff are not associated to the facility.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023

Link to Parent Document Below:

FACILITY NAME: MARSTON CORPORATION	FACILITY NUMBER: 079201176
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/27/2023 Section Cited CCR 87555(b)(26)	1 2 3 4 5 6 7	Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility will purchese more nonperishable foods. Proof of correction will be sent to CCLD by POC date.
	8 9 10 11 12 13 14	The kitchen, and food storage areas do not have a enough nonperishable foods	8 9 10 11 12 13 14
Type B 09/27/2023 Section Cited CCR87555(b)(21)	1 2 3 4 5 6 7	...refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility will adjust the tempature of the garage fridge or discontinue use of the fridge. Proof of correction will be sent to CCLD by POC date.
	8 9 10 11 12 13 14	The temperature in the garage fridge was measured at 45 Degree F	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023

Link to Parent Document Below:

FACILITY NAME: MARSTON CORPORATION	FACILITY NUMBER: 079201176
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/27/2023 Section Cited CCR 87618(b)(3)(B)	1 2 3 4 5 6 7	Ensuring that the use of oxygen equipment meets the following requirements: "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility agrees to add signs stating "No Smoking-Oxygen in Use" or remove the oxygen containers. Proof of correction will be sent to CCLD by POC date.
	8 9 10 11 12 13 14	Containers of oxygen are being stored in the closet of one of the bedrooms.	8 9 10 11 12 13 14
Type B 09/15/2023 Section Cited CCR87303(e)(2)	1 2 3 4 5 6 7	Faucets used by residents shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F requirement is not met as evidenced by:	1 2 3 4 5 6 7	POC cleared during visit.
	8 9 10 11 12 13 14	Water temperature was measured at 134.1 F.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023

Link to Parent Document Below:

FACILITY NAME: MARSTON CORPORATION	FACILITY NUMBER: 079201176
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/27/2023 Section Cited HSC 87303(c)	1 2 3 4 5 6 7	All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility agrees to repair or replace the screen. Proof of correction will be sent to CCLD by POC date.
	8 9 10 11 12 13 14	The window screen in the back bedroom is ripped	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Jill Clancy-Czuleger LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023