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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700213
Report Date: 10/27/2022
Date Signed: 10/27/2022 03:15:35 PM

Document Has Been Signed on 10/27/2022 03:15 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MIH CARE HOMEFACILITY NUMBER:
392700213
ADMINISTRATOR:MAI XIONGFACILITY TYPE:
735
ADDRESS:7514 CORAL LNTELEPHONE:
(209) 244-3898
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: 3DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Whitney MontijoTIME COMPLETED:
03:30 PM
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On 10/27/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1-year annual visit. LPA Jensen met with Administrator Whitney Montijo and explained the purpose of today's visit. Whitney holds a current Administrator certificate # 6053647735 which expires 9/13/2023.

LPA Jensen toured the facility with the administrator including 4 bedrooms, living room, kitchen, office, 2 bathrooms, laundry room and grounds. There are currently 3 residents. The grounds were clear of obstruction and well maintained. Patio furniture and a stationary bicycle was observed in the backyard for use by the residents. There are no bodies of water on the property.

The interior of the facility was observed to be sanitary and free of odor. The LPA was screened for COVID-19 upon entering and signed in. All required signs were posted in prominent areas in the facility. There was adequate furniture and lighting observed throughout. Night lights are available in the hallways. An ample supply of linen was available. LPA Jensen observed the medication to be locked and inaccessible to residents. The knives, sharp objects and toxins were also locked and inaccessible to residents. The facility keeps a supply of emergency food and medical supplies on hand with every item logged and a corresponding expiration date. Their are 3 first aid kits on hand and the first aid kits were observed to be complete. The fire extinguisher was last serviced in October of 2022 and is in compliance. The fire alarm and carbon monoxide detectors were tested and found to be in good working order. The facility conducts and logs fire drills every month.

There were numerous activities observed that are available for the residents. LPA Jensen observed in excess of a 2 day supply of perishable food and 7 day supply of non-perishable food. All food is labeled with expiration dates. The facility administrator was preparing spaghetti and taquitos for a holiday party that was taking place this evening.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MIH CARE HOME
FACILITY NUMBER: 392700213
VISIT DATE: 10/27/2022
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The temperature in the home was 70 degrees which falls within the required regulatory range of 68-85 degrees Farenheit. The water temperature was measured at 115.4 which falls within the required regulatory range of 105-120 degrees Farenheit. A water temperature log is maintained by staff. All window screens were observed to be in good repair. The bathrooms were equipped with grab bars at the toilet and in the bath. Non-slip mats were available for the bath.

2 staff were present during the course of the visit and both were confirmed to be fingerprint cleared and associated to the facility. 3 of 3 resident files were reviewed and found to be complete.

LPA Jensen requested and was provided with a current copy of the liability insurance as well as a current LIC 500.

The Infection Inspection Control Tool was utilized during the course of this visit. The facility is in substantial compliance with the California Code of Regulations (CCR) Title 22, Division 6 and the Health and Safety Code.

An exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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