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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002565
Report Date: 10/21/2020
Date Signed: 11/03/2020 08:57:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MARY'S ELDERLY CARE HOME IIFACILITY NUMBER:
347002565
ADMINISTRATOR:MAGDA, MARYFACILITY TYPE:
740
ADDRESS:8551 NARCISSUS COURTTELEPHONE:
(916) 681-9030
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 0DATE:
10/21/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Mary MagdaTIME COMPLETED:
02:59 PM
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 Licensing Program Analyst (LPA) Anthony Tuck conducted a case management virtual inspection on 10/21/2020 due to licensee/administrator Mary Magda has decided to cease operation of facility. Licensee submitted facility closure plan to CCL as well as provided residents in care 60 day eviction notice on 08/28/2020, as required. There were no resident in care, and resident were relocated during 60 day eviction period LPA inspected facility virtually with administrator to ensure there were no remaining residents in care. There are no residents or overt signs of any residents being provided care and supervision. LPA confirmed facility closure. The Licensee will email LPA a list of locations for each resident new address location.

LPA requested the license to be mailed to the Community Care License (CCL) Regional Office. The Facility is closed effective 10/21/2020. Due to the aforementioned, facility closure shall be processed in CCL database.

Link to survey for Facility Closure provided to Mary.

www.surveymonkey.com/r/facilityclosure


Exit interview conducted and a copy of this report was emailed to the administrator.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
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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