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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005680
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:48:26 PM


Document Has Been Signed on 09/21/2023 03:48 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:IMMACULATE CARE HOMEFACILITY NUMBER:
347005680
ADMINISTRATOR:MUIRURI, MARYIMMACULATEFACILITY TYPE:
740
ADDRESS:8892 MONTEREY OAKS DRIVETELEPHONE:
(916) 236-7339
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 0DATE:
09/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Mary MuiruriTIME COMPLETED:
03:50 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 Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit to follow up on an incident report. LPA Moleski met with facility administrator Mary Muiruri and explained the purpose of the visit.

LPA Moleski reviewed two incident reports. The reports described a resident (R1) becoming weak and needing medical attention. According to Muiruri, R1 died after transferring to another facility.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Muiruri.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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 1