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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001644
Report Date: 07/26/2023
Date Signed: 07/27/2023 08:26:08 AM

Document Has Been Signed on 07/27/2023 08:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MARCELLA GREEN FAMILY HOMEFACILITY NUMBER:
317001644
ADMINISTRATOR:GREEN, MARCELLAFACILITY TYPE:
735
ADDRESS:11742 JONES STREETTELEPHONE:
(530) 863-8866
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 2DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marcella GreenTIME COMPLETED:
03:00 PM
NARRATIVE
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On 7/26/2023 LPA Tryon visited the facility to do an annual visit. LPA met with licensee Marcella Green.
LPA toured the house including common areas, kitchen, bedrooms, bathrooms, storage, yard.
The house appears to be in general compliance overall. Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable supplies. Medications, cleaners, knives, etc. are secured. LPA reviewed client files and staff files, Emergency/Disaster plan, etc. Smoke detectors installed, new fire extinguisher present and fully charged. No hazards or obstructions noted.

LPA reviewed the CARES Tool with licensee. Licensee appears to be in compliance in all areas with the exception that her First Aid Certification needs to be renewed. Otherwise, LPA found no other deficiencies.

The following deficiency is cited as per Title 22 Regulations and the Health and Safety Code.
Exit interview conducted, Appeal Rights provided.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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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Document Has Been Signed on 07/27/2023 08:26 AM - It Cannot Be Edited


Created By: Todd Tryon On 07/26/2023 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MARCELLA GREEN FAMILY HOME
FACILITY NUMBER: 317001644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1out of 1 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2023
Plan of Correction
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Licensee will ensure that her First Aid Certification is renewed prior to POC due date of 8/26/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Todd Tryon
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


LIC809 (FAS) - (06/04)
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