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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004351
Report Date: 06/01/2023
Date Signed: 06/09/2023 08:23:04 AM

Document Has Been Signed on 06/09/2023 08:23 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:MAPEL HOUSEFACILITY NUMBER:
347004351
ADMINISTRATOR:TATEISHI, GARYFACILITY TYPE:
735
ADDRESS:4616 MAPEL LANETELEPHONE:
(916) 962-2199
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:CaregiversTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 6/1/23 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator arrived at the facility to assist with the visit.

LPA reviewed five client and 2 staff files. All were found to be complete. R3 is in process of updating their LIC 602 and facility is awaiting the most recent IPP.

LPA requested for documents such as LIC 500.

LPA advised that infection control and Emergency plans be reviewed at least annually and updated as needed.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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