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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202689
Report Date: 03/06/2024
Date Signed: 04/05/2024 05:44:27 PM


Document Has Been Signed on 04/05/2024 05:44 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SONGBIRD IN THE COUNTRYFACILITY NUMBER:
275202689
ADMINISTRATOR:MAZERIK, BETHFACILITY TYPE:
740
ADDRESS:15961 TORO HILLS AVENUETELEPHONE:
(831) 998-8708
CITY:SALINASSTATE: CAZIP CODE:
93908
CAPACITY:12CENSUS: 9DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee Keri Mazerik, Continual Administrator's Certification expires 10/26/2024. There are currently 10 residents who reside at this home and there is 4 residents on hospice at this time.


LPA Hurt reviewed 4 facility staff records, and 4 facility resident records.
Staff 1 is missing required Health screening LIC 503, and TB test.

LPA Hurt toured the facility including bedrooms, bathrooms, and outdoor areas. The facility is clean and in good repair.


There following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Keri Mazerik, and copy of report left at facility
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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