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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700793
Report Date: 04/14/2022
Date Signed: 04/14/2022 03:39:10 PM

Document Has Been Signed on 04/14/2022 03:39 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:MMK PARTNERS IN CARE, INC.FACILITY NUMBER:
392700793
ADMINISTRATOR:EMPERADOR, ANN KRISTINEFACILITY TYPE:
735
ADDRESS:2196 KINGSBURY DRIVETELEPHONE:
(916) 833-6978
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 4CENSUS: 4DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Joy Bernardino, Direct Support StaffTIME COMPLETED:
03:45 PM
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On 04/14/2022 at 11:45 am, Licensing Program Analysts (LPA) T. White and R. Campbell spoke with Direct Support Staff (DSP), Joy Bernardino regarding facility risk assessment questions. DSP confirmed no staff or clients have experienced symptoms within the last 10 days. At 11:45 am, LPA T. White and LPA R. Campbell arrived unannounced to conduct a required 1-year Annual inspection. LPA met Direct Support Staff, Joy Bernardino and explained the purpose of today’s inspection. LPAs were allowed entry into the facility that is licensed to serve a total capacity of 4 clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 72 degree Fahrenheit. LPAs observed lighting in all rooms as adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 110 degree Fahrenheit. All toilets, hand washing, and bathing areas are safe, sanitary and in operating condition. There is a minimum of 7-day of nonperishables and 2-day of perishables foods.

Smoke detector and carbon monoxide detectors are interconnected with the fire department. Fire extinguisher was last serviced on March 04, ,2021. First aid kit was observed to be complete. Fire drill was last conducted on 04/04/2022. LPAs reviewed four client files and three staff record files. LPAs reviewed three of four client P&I monies.

The following forms to be updated and submitted to CCLD by 04/22/2022:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 610E Emergency Disaster Plan

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview conducted with Direct Support Staff. LPA had printer issues and a copy of report was emailed.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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