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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005680
Report Date: 04/24/2023
Date Signed: 04/24/2023 01:01:34 PM


Document Has Been Signed on 04/24/2023 01:01 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: 2DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Balbino Garcia - care staffTIME COMPLETED:
01:15 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 (LPAs) Vincent Moleski and Jason Lund arrived unannounced on Monday, April 24, 2023, to conduct an annual inspection. LPAs Moleski and Lund met with staff member Balbino Garcia and explained the purpose of the visit. LPA Moleski spoke with administrator Maryimmaculate Muiruri over the phone. Muiruri said Garcia would be able to sign this report.

LPAs Moleski and Lund reviewed two resident files (R1-R2) and one staff file (S1). LPAs and Garcia observed first aid training certification for him dated 12/13/17 which expired on 12/14/19.

LPAs Moleski and Lund interviewed R1, R2, and S1. Muiruri's administrator certificate (6035466740) expires on May 26, 2023.

LPAs Moleski and Lund toured the facility with Garcia and inspected the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. Furniture and furnishings were sufficient to meet the needs of the clients.

LPA Moleski measured the water temperature, which was within the required range of 105 and 120 degrees Fahrenheit. LPAs Moleski and Lund observed sufficient seven-day non-perishable and two-day perishable food supplies. LPAs Moleski and Lund observed an up-to-date fire extinguisher and working smoke and carbon detectors. A complete first aid kit was observed LPA observed centrally stored medications secure from residents which was locked and inaccessible.

This facility is being cited per HSC Section 1569.618(c)(3). A copy of this report and appeal rights were left with Garcia.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
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 2


Document Has Been Signed on 04/24/2023 01:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 347005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review of the staff member's file, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2023
Plan of Correction
1
2
3
4
Licensee will acquire new first aid certification for staff member.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2