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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701073
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:24:05 PM

Document Has Been Signed on 06/22/2022 04:24 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-5 CARE HOME, INCFACILITY NUMBER:
392701073
ADMINISTRATOR:WHITNEY MONTIJOFACILITY TYPE:
735
ADDRESS:9546 BISMARK PL.TELEPHONE:
(209) 244-3898
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 4CENSUS: 4DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Whitney Montijo, Facility AdministratorTIME COMPLETED:
03:15 PM
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LPA Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by Whitney Montijo. LPA explained the purpose of the visit and staff accompanied LPA on the facility inspection.

LPA Jacobs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed facility with a current census of 4. There are 4 client bedrooms and 2 client bathrooms. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing and other signage noted. Medications noted to be locked to residents in care. LPA also conducted the infection control domain tool.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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-5 CARE HOME, INC
FACILITY NUMBER: 392701073
VISIT DATE: 06/22/2022
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LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were checked June 2022 and are in compliance. Facility has an emergency food and water supply in a separate storage area in kitchen. First Aid jit on-site. All staff on-site have current fingerprint clearances. Water was measured at 113.5 degrees F. LPA requested the following documents to be updated: LIC 500 and LIC 309 as needed.

Per California Code of Regulations, Title 22 no deficiencies were observed during this visit. Exit interview was held and a report was given to Mss. Montijo.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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