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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701108
Report Date: 06/21/2024
Date Signed: 06/24/2024 12:21:42 PM

Document Has Been Signed on 06/24/2024 12:21 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MB ADULT RESIDENTIAL CARE HOMESFACILITY NUMBER:
392701108
ADMINISTRATOR/
DIRECTOR:		KAUR, KULJITFACILITY TYPE:
735
ADDRESS:15833 SOUTH AIRPORT WAYTELEPHONE:
(209) 679-9938
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 0DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kuljit KaurTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Unannounced Annual visit made out to this facility on 06/21/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Kuljit Kaur. A brief interview was conducted with the facility designated Administrator at this time.
This facility was also seeking vendorization from Valley Mountain Regional Center (VMRC) to be able to accept and retain Level 4I regional center clients at this time.
Current census was 0 residents.
It was learned that this facility will not be providing care for residents under hospice at this time.
It was learned that this facility will not be providing care for residents diagnosed with dementia at this time.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Kuljit Kaur. Additional forms and documents were reviewed to make sure that the recertification process was initiated pending certificate renewal at this time.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet and supplies, located in the facility kitchen cabinet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms 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 and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closets were observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MB ADULT RESIDENTIAL CARE HOMES
FACILITY NUMBER: 392701108
VISIT DATE: 06/21/2024
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Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually purchased with a visible receipt attached from the local hardware store and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (0) facility resident records was conducted and noted on the following LIC 858 form.
A review of (1) facility staff records was conducted and noted on the following LIC 859 form.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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