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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701028
Report Date: 05/09/2024
Date Signed: 05/09/2024 03:52:59 PM

Document Has Been Signed on 05/09/2024 03:52 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 LLCFACILITY NUMBER:
342701028
ADMINISTRATOR/
DIRECTOR:
LEE, KEVINFACILITY TYPE:
740
ADDRESS:317 NATOMA ST.TELEPHONE:
(916) 831-7972
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 15CENSUS: 12DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Staff- Elizabeth SwabyTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 05/09/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak and Associate Governmental Program Analyst (AGPA) Talia Silva arrived at the facility unannounced to conduct a required 1 year annual inspection. LPA met with Staff Elizabeth Swaby and explained the purpose of the visit.

LPA and Staff conducted a tour of the interior and exterior of the facility. Areas toured include but are not limited to: resident rooms, bathrooms, dining room, kitchen, outdoor area and the common areas. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins, cleaning supplies and knives are locked and inaccessible to residents in care. Hot water temperature was measured at 108.9 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 75 degrees. First aid kit was completed. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in the hallway, which was last inspected on 06/21/2023. LPA observed required Licensing posters posted throughout the facility. LPA conducted one (1) resident interview and one (1) staff interview.

LPA reviewed three (3) personnel files and six (6) residents' files. Staff have annual training as well as first aid and CPR. Residents files contain signed admission agreements, updated physician reports, Identification sheet, consent forms, appraisals needs and service plan, and resident rights.

LPA requested a copy of the LIC 500, LIC308 and current liability insurance to be emailed to LPA by 05/13/2024.

No deficiencies are being cited.
Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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