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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002912
Report Date: 07/17/2024
Date Signed: 07/17/2024 12:14:23 PM

Document Has Been Signed on 07/17/2024 12:14 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:MC HOME CARE, INC.FACILITY NUMBER:
345002912
ADMINISTRATOR/
DIRECTOR:		MONTE, JACELYNFACILITY TYPE:
735
ADDRESS:7628 BLACKTHORNE WAYTELEPHONE:
(916) 560-9201
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 4CENSUS: 4DATE:
07/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Administrator- Jacelyn MonteTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 07/17/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Case Management Incident visit. LPA met with Administrator- Jacelyn Monte, and explained the purpose of the visit.

The purpose of the visit is to gather additional information regarding a Special Incident Report (SIR) that was sent to Community Care Licensing (CCL) on 07/15/24. The report indicates that Resident #1 (R1) had left the facility on 07/12/24 at 9:30 AM to run errands. By 5:00PM R1 still had not returned to the facility. Administrator made multiple attempts to contact R1 but did not get a response. Administrator then started to call local hospitals as well as the Police Department. The Police Department was able to locate R1 at a hospital.

During today’s visit LPA and Administrator further discussed the incident that occurred. Administrator stated that the hospital would not give Administrator any information regarding R1. At this time R1 still has not returned to the facility. Additionally, LPA obtained a copy of R1s, LIC602 and IPP.

At this time, this incident remains under review by the Department.



Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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