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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700458
Report Date: 11/16/2023
Date Signed: 11/16/2023 10:39:11 AM


Document Has Been Signed on 11/16/2023 10:39 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:MUIRFIELD A HOME FOR THE ELDERLYFACILITY NUMBER:
342700458
ADMINISTRATOR:LOBO, ANALIZAFACILITY TYPE:
740
ADDRESS:7541 MUIRFIELD WAYTELEPHONE:
(916) 424-4553
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 6DATE:
11/16/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Marilyn Carpio - House ManagerTIME COMPLETED:
11:00 AM
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 Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required annual inspection visit. LPA met with House Manager and explained purpose of visit. Administrator certificate expires on 11/8/2024. The facility is licensed to served six non-ambulatory residents. Hospice waiver approved for four residents. There are currently six residents and no residents are on hospice at this time.

LPA and house manager inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. Hot water temperature was observed to be 114.5 degrees Fahrenheit. Facility thermostat observed at 75 degrees Fahrenheit. Food supply is adequate for two day perishable and seven day nonperishable.

LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher was last inspected on 11/17/2022 and first aid kit was current. LPA checked medication storage and found medication to be locked away and inaccessible to residents. The facility mitigation plan was submitted to community care licensing and it was approved on 2/16/2021.

LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed four resident and four staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete.

LPA requested the following updated documents to be submitted via email to community care licensing by 12/4/2023: LIC 308 - Designation of Administrator, copy of deed, copy of administrator's certificate, and liability insurance.
ruth.wallace@dss.ca.gov

Per the California Code of Regulations, Title 22 no deficiencies were observed or cited. 

Exit interview held with house manager. A report and LIC 811 (Confidential Names) was left at the facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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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