347004961-8-31-2023-27-AS-PLEE-CV8U9Y-20230831152353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004961
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:24:30 PM

Document Has Been Signed on 08/31/2023 03:24 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	MARYLOU'S HOME CARE		FACILITY NUMBER:	347004961
ADMINISTRATOR:	APUYA, ROMEO		FACILITY TYPE:	740
ADDRESS:	4194 ENGLE ROAD		TELEPHONE:	(916) 482-4143
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	6	CENSUS: 5	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Maureen Grant		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/31/2023 at 1:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff, Maureen Grant. LPA Lee explained the purpose of the visit. Direct care staff, Maureen Grant assisted with today’s visit. Administrator certificate # is 6038096740 and will expire on 02/15/2024. The current census is 5 with 1 facility staff. This facility is a single story building licensed to serve six (6) non-ambulatory residents and approved for 2 hospice residents. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee observed sufficient seven day non-perishable and two day perishable food supplies. Direct care staff, Maureen pulled out three condiments from the refrigerated and the expiration date was current. Hot water temperature was measured at 121.5 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher was last serviced on 09/30/2022. LPA Lee observed the facility has a has a public telephone in the kitchen and the facility have the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 74 degrees Fahrenheit. A tour of the garage was conducted. LPA Lee checked medication storage and found medication to be locked away and inaccessible to resident. LPA Lee reviewed 2 out of 5 Centrally Stored Medication Destruction Records (CSDMR). LPA Lee requested resident and staff files for review. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MARYLOU'S HOME CARE	FACILITY NUMBER: 347004961
	VISIT DATE: 08/31/2023

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LPA Lee reviewed 3 out of 5 resident files and 2 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 09/08/2023 by 5:00 PM by end of day:

(1) LIC 308 Designation of Administrative Responsibility

(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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