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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004961
Report Date: 08/05/2022
Date Signed: 08/05/2022 11:46:21 AM


Document Has Been Signed on 08/05/2022 11:46 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:MARYLOU'S HOME CAREFACILITY NUMBER:
347004961
ADMINISTRATOR:APUYA, ROMEOFACILITY TYPE:
740
ADDRESS:4194 ENGLE ROADTELEPHONE:
(916) 482-4143
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Geromina Bautista and Maureen WillandsTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection on 08/04/2022. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations.

The LPA toured the facility with Geromina Bautista and Maureen Willands on 08/05/2022 at 11:13 AM.

Administrator holds current certificate and expires. The facility is licensed for 6 non-ambulatory residents, and has a hospice waiver for 2 residents. There are currently 5 residents who reside at this facility.

The licensee has submitted an LIC 808 Covid-19 mitigation plan and infection control plan. The facility has one main entry screening point, and has a 30 day supply of PPE. The facility has Covid-19 postings throughout the facility, and conducts daily disinfecting cleaning. The facility fire extinguisher, carbon detector, and smoke detectors are in good repair. The facility has a first aid kit, and medications are locked. LPA Martinez reviewed 1 employee file and 1 resident file, and the files were up to date. The exterior of the facility is clear of debris.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


Exit interview held and a report given at the end of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
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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