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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002912
Report Date: 09/01/2023
Date Signed: 09/05/2023 09:35:28 AM

Document Has Been Signed on 09/05/2023 09:35 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:MC HOME CARE, INC.FACILITY NUMBER:
345002912
ADMINISTRATOR:MONTE, JACELYNFACILITY TYPE:
735
ADDRESS:7628 BLACKTHORNE WAYTELEPHONE:
(916) 560-9201
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 4CENSUS: 2DATE:
09/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jacelyn MonteTIME COMPLETED:
01:00 PM
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On 9/1/2023 LPA Tryon visited the facility to do an annual review. LPA met with licensee Jacelyn Monte.
The facility currently has 2 residents; and another resident is scheduled to move in soon.

LPA toured the facility with licensee including common areas, kitchen, bathrooms, bedrooms, hallways, yard. The home is clean and nicely furnished, has appropriate furniture in client bedrooms. Food supplies are appropriate to meet the requirement of 2 days perishable and 7 days non-perishable supplies. Food appears of good quality. Home has functioning smoke detectors, fire extinguishers that were charged and serviced recently, and carbon monoxide detectors. Medications are centrally stored and locked in a cabinet. Knives and other potentially dangerous items are locked under the kitchen sink. The home has appropriate supplies of clean bedding, towels, etc. Hallways, exits are free of obstruction.

LPA reviewed 2 staff files and 2 resident files. There are currently 2 staff, but 2 more are scheduled to start work soon.

LPA reviewed the CARE Tool with licensee.

The home appears to be in substantial compliance with the regulations at this time. No deficiencies were cited.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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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