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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700896
Report Date: 06/27/2023
Date Signed: 06/27/2023 12:07:32 PM

Document Has Been Signed on 06/27/2023 12:07 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MVP CAREHOMEFACILITY NUMBER:
342700896
ADMINISTRATOR:PURUGGANAN, EVELETH R.FACILITY TYPE:
735
ADDRESS:5914 WEDGEWOOD AVENUETELEPHONE:
(909) 384-2276
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
06/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Eveleth PuruggananTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Cassie Yang and Jaynae Boyles arrived unannounced at the facility to conduct a case management visit regarding an incident the Department received. LPAs met with Administrator (Admin), Eveleth Purugganan, and explained the purpose of the visit.

LPAs and Admin discussed the Facility Action Report dated 5/18/2023 conducted by Alta California Regional Center. Admin explained to LPAs that there was a medication error listed on the Medication Administration Record. Admin stated that based on the online doctor's record, the vitamin was listed as one tablet per day but on the physical copy of the order, it was listed as two. Admin informed LPAs corrections and staff training has been made.

As a result of today's visit, no deficiencies was cited.

Exit interview conducted and a copy of the report was provide.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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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