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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700872
Report Date: 12/13/2023
Date Signed: 12/13/2023 10:55:13 AM

Document Has Been Signed on 12/13/2023 10:55 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:MASON'S HOME, LLCFACILITY NUMBER:
342700872
ADMINISTRATOR:WONG, SALLYFACILITY TYPE:
735
ADDRESS:4521 EXCELSIOR RDTELEPHONE:
(916) 402-3830
CITY:MATHERSTATE: CAZIP CODE:
95655
CAPACITY: 4CENSUS: 4DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Sally Wong - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted a required 1 year annual inspection visit. LPA met with administrator and explained purpose of visit. Administrator certificate expires June 2, 2024.

LPA and administrator toured the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times.

LPA measured the water temperature, temperature measured at 109.5 degrees F. Fire extinguishers last inspected on December 9, 20222. Smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.
LPA reviewed two resident and three staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility.

LPA requested the following updated documents to be submitted via email to community care licensing by 12/20/2023: LIC 308 - Designation of Administrator, LIC 402 - Copy of Surety Bond, and a copy of administrator's certificate.
ruth.wallace@dss.ca.gov

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted with administrator, A copy of this report and LIC 811 (Confidential Names) was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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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