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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701108
Report Date: 02/07/2022
Date Signed: 02/08/2022 02:25:34 PM

Document Has Been Signed on 02/08/2022 02:25 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:MB ADULT RESIDENTIAL CARE HOMESFACILITY NUMBER:
392701108
ADMINISTRATOR:KAUR, KULJITFACILITY TYPE:
735
ADDRESS:15833 SOUTH AIRPORT WAYTELEPHONE:
(209) 679-9938
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 0DATE:
02/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kuljit KaurTIME COMPLETED:
12:00 PM
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Announced Prelicensing visit made out to this facility by LPA Charlie Yang on 02/07/2022. This LPA was met by the Applicant, Kuljit Kaur, who was briefly interviewed prior to the facility walk through.
This Applicant is seeking licensure for a 6-bed Adult Residential Facility to accept and retain ambulatory only residents at this time. It was also learned that this Applicant is in the process of vendorization through Valley Mountain Regional Center for a level 4I care home.
Current census was 0 residents.
Tour of the this facility was conducted.
A tour of the living room, dining room, and all other interior areas intended for use by the residents was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the kitchen was conducted. Food storage for 2-day perishable supply was observed to be sufficient and able to meet the needs of the residents at this time. A review of the nonperishable food supply was observed to be sufficient and able to meet the needs of the residents at this time.
Cabinets and drawers were opened and reviewed for adequate plates, utensils, and cook ware at this time.
Fire extinguisher, located in the kitchen area, was reviewed for annual purchase date or inspection date.
A tour of the facility resident rooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken in the resident restrooms to make sure that they were within the allowed range of 105-120 degrees.
A review of the medication cabinet was conducted. First aid kit was observed to be present and contained all of the required components at this time.
A review of the storage cabinet housing cleaning agents and supplies was observed to be locked and made inaccessible to the residents at this time.
A tour of laundry area was conducted. It was observed that there were two laundry areas at this time. Laundry detergents and bleach were observed to be locked and made inaccessible at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
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: MB ADULT RESIDENTIAL CARE HOMES
FACILITY NUMBER: 392701108
VISIT DATE: 02/07/2022
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A tour of the facility exterior grounds was conducted.
A review of the facility perimeter fence, side fence, and emergency exits was conducted.

The following items will need to be updated and brought into compliance prior to approval for licensure at this time:
  1. Turn down the hot water heater so that the hot water being dispensed is within the range of 105-120 degrees since it was measured at 134.4 degrees
  3. Update and maintain personnel record(s) on site available for review by CCL
  5. Update and maintain resident record(s) on site available for review by CCL
  7. Maintain proof of annual purchase or maintenance of all facility fire extinguishers
  9. Update the LIC 999 to properly reflect all rooms and areas in this facility intended for resident use, staff use, and storage purposes
Upon completion of the above items, this Applicant will contact this LPA to conduct a follow up Prelicensing visit at later scheduled date and time. Website for Community Care Licensing Division given to the Applicant at this time in order to review Title 22 rules and regulations as well as complete and print out forms.
www.ccld.ca.gov

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
LIC809 (FAS) - (06/04)
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