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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700872
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:43:35 PM

Document Has Been Signed on 09/18/2024 04:43 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MASON'S HOME, LLCFACILITY NUMBER:
342700872
ADMINISTRATOR/
DIRECTOR:		WONG, SALLYFACILITY TYPE:
735
ADDRESS:4521 EXCELSIOR RDTELEPHONE:
(916) 402-3830
CITY:MATHERSTATE: CAZIP CODE:
95655
CAPACITY: 4CENSUS: 4DATE:
09/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:31 PM
MET WITH:Sally WongTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 9/18/24 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator, Sally Wong. LPA met with Sally Wong and a brief interview followed.

LPA received an incident report regarding a resident R1 who recently developed new behaviors not previously seen. LPA requested the following documents:

For R1 and R2:
LIC 602
IPP
Emergency Contact /ID Sheets.

Due to time constraints, this LPA will continue this case management at a later date.

According to the California Code of Regulations, no deficiencies were observed during today's visit. A copy of this report was provided and an exit interview was conducted with the Designated Facility Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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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