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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342701028
Report Date:
11/09/2023
Date Signed:
11/09/2023 03:08:11 PM
Document Has Been Signed on
11/09/2023 03:08 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:
MKS QUALITY CARE LLC
FACILITY NUMBER:
342701028
ADMINISTRATOR:
LEE, KEVIN
FACILITY TYPE:
740
ADDRESS:
317 NATOMA ST.
TELEPHONE:
(916) 831-7972
CITY:
FOLSOM
STATE:
CA
ZIP CODE:
95630
CAPACITY:
15
CENSUS:
11
DATE:
11/09/2023
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Caregiver- Carise Swaby
TIME COMPLETED:
03:15 PM
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On 11/09/2023 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassie Yang arrived at the facility unannounced to do a case management regarding an incident report that the department received. LPAs met with caregiver Carise Swaby and explained the purpose of the visit.
LPAs and caregiver discussed the incident that occurred on 10/28/2023 regarding R1s fall. Caregiver informed LPAs that the fall occurred shortly before her shift but she contacted emergency medical services right away at approximately 7:05 AM.
During todays visit LPAs spoke with R1 who reported to be recovering well. LPAs observed R1 to have a cast on her right arm. R1 informed LPAs there are no concerns at the moment.
LPAs obtained a copy of R1s 601 and 602.
Exit interview conducted and a copy of report left.
SUPERVISOR'S NAME:
Laura Munoz
TELEPHONE:
(916) 263-4743
LICENSING EVALUATOR NAME:
Cheyenne Ratajczak
TELEPHONE:
(916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE:
11/09/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/09/2023
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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