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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700872
Report Date: 12/19/2024
Date Signed: 12/19/2024 12:28:15 PM

Document Has Been Signed on 12/19/2024 12:28 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: 3DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Sally WongTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 12/19/24. There was no one present at the facility - staff and 1 client were out doing and errand and the other 2 clients were at a day program. LPA contacted the Administrator. The Administrator along with the staff and client running errands, arrived shortly afterward. LPA identified herself upon arrival, stated the purpose of the visit. LPA met with Sally Wong and a brief interview followed. LPA requested the following documents:

·LIC 500: Personnel Report
·LIC 308: Designation of Administrative Responsibility
·LIC 309: (for any LLC or Corp) if applicable
·LIC 402: Surety Bond, if applicable
·LIC 610E: Emergency Disaster Plan
·Copy of Liability Insurance

LPA noted the Administrator's certificate # 7034029735 and it expires on 08/16/26.        

LPA inspected resident rooms. All rooms were single occupancy and had the required furniture furnishings and lighting to be in compliance at the present time. The doors to all of the rooms were also equipped with locks for residents to use if they so chose.

The LPA inspected the kitchen.  All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. All food items were dated, labeled, and stored according to regulations.

LPA inspected the bathrooms.  Each contained soap, paper towels, and trash cans as required. Personal hygiene items were present, toxic cleaning supplies were not. Hot water was measured to ensure the temperature was between 105 and 120 degrees Fahrenheit in order to be in compliance.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 342700872
VISIT DATE: 12/19/2024
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LPA inspected the laundry room and garage. The garage contained locked cabinets where laundry detergents were stored for staff use. The garage was organized and stored some furniture, personal care/hygiene and seasonal items. LPA observed that staff had adequate room to park the car in the garage.

The fire extinguisher was last serviced on 01/10/24 by River City Fire Extinguisher Company and was in compliance at the time of inspection.
 
The LPA observed medications were stored in a locked closet in the living room and inaccessible to residents in care. LPA reviewed storage and destruction procedures. LPA reviewed the Centrally Stored Medication Log as well as the Destruction Log and both were in compliance at the time of this inspection. LPA reviewed the PRN Log to ensure that it was also in compliance.

The LPA and the Administrator then inspected the exterior of the building and grounds.  There were no bodies of water present and the yard was completely fenced in.  There was a patio area under a shade tree with furniture for residents to enjoy. All window screens and gutters were in good repair at the time of inspection. There were 2 sheds present in the backyard. One was for storage of resident seasonal belongings, the other contained household and yard equipment. There were no toxic items or sharps present in either shed at the time of this inspection.

LPA observed an activity calendar, menu calendar, facility license, IF YOU SEE SOMETHING, SAY SOMETHING sign, along with resident and employee rights posters. 

LPA reviewed LIC 500 and compared it to the Guardian Roster to ensure that all the employees had their required background clearances. All were in compliance at the time of this inspection.

LPA conducted a file review for 2 staff and 2 residents. All were in compliance at the time of this inspection.

According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided.

Exit interview.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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