<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004961
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:44:58 PM


Document Has Been Signed on 09/10/2024 12:44 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 CAREFACILITY NUMBER:
347004961
ADMINISTRATOR:APUYA, ROMEOFACILITY TYPE:
740
ADDRESS:4194 ENGLE ROADTELEPHONE:
(916) 482-4143
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maureen GrantTIME COMPLETED:
12:50 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
Licensing Program Analysts (LPA) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPAs Moleski and Williams met with facility administrator Geronima Bautista and explained the purpose of the visit.

LPAs Moleski and Williams reviewed four resident files (R1-R4) and three staff files (S1-S3). R3's LIC 602 is over a year old, and R3 is diagnosed with dementia. However, Bautista shared that she has repeatedly attempted to receive R3's updated LIC 602 from their physician. During this visit, Bautista reached out to the physician again, but they sent TB test results instead of the updated LIC 602. Bautista provided documentation from the TB test and other medical documentation showing that R3 has been seen by a physician previously this year. LPAs Moleski and Williams provided technical assistance regarding medical reassessment requirements. Bautista said she will provide LPA Williams with the updated LIC 602 when received from R3's physician.

LPAs Moleski and Williams toured the facility with Bautista and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 119 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPAs Williams and Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPAs Moleski and Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPAs Moleski and Williams observed a locked cabinet for the storage of medication. LPAs Moleski and Williams observed locked cabinets for the storage of cleaning solutions and knives.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 09/10/2024
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
26
27
28
29
30
31
32
LPAs Moleski and Williams observed prescribed medication stored in R2's room. According to R2's LIC 602, R2 is able to store and administer his own medication. LPAs Moleski and Williams provided technical assistance regarding medication storage requirements.

LPA Moleski interviewed one staff member (S2) and two residents (R1-R2).

No deficiencies were cited during this visit. Technical assistance was provided as described above. An exit interview was conducted and a copy of this report was left with staff member Maureen Grant.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2