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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701028
Report Date: 09/26/2024
Date Signed: 09/26/2024 09:48:16 AM

Document Has Been Signed on 09/26/2024 09:48 AM - 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: 11DATE:
09/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff- Elizabeth SwabyTIME VISIT/
INSPECTION COMPLETED:
09:55 AM
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On 09/26/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a case management visit regarding an incident that occurred on 09/14/24 LPAs met with Staff Elizabeth Swaby and explained the purpose of the visit.

The department received an Unusual Incident Report (LIC624) from the facility stating that Resident #1 (R1) had taken another residents medication. Staff had set R1s lunch medication in front of them and stated to R1 here is your medications. Staff had also set Resident #2 (R2) medication down in front of themselves while standing next to R1. R1 reached out to grab their medication and accidentally swallowed R2s medication before staff was able to stop R1.

During today's visit LPAs obtained a copy of R1s LIC602. LPAs observed R1 to be up and moving around. LPAs spoke with staff who stated R1 had been monitored closely since the incident and has had no reactions.

At this time, deficiencies are not being cited.



An exit interview conducted and report provided was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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