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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 05/24/2022
Date Signed: 05/24/2022 04:35:03 PM


Document Has Been Signed on 05/24/2022 04:35 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:MOTHER MARY CARE HOMEFACILITY NUMBER:
392701157
ADMINISTRATOR:ALVAREZ, JEANFACILITY TYPE:
740
ADDRESS:492 E. FRISBEE LANETELEPHONE:
(209) 888-4080
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY:6CENSUS: 0DATE:
05/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jean AlvarezTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Michael Bilger conducted an announced pre-licensing visit to this facility on 05/24/2022 at 2:00pm and was met by the Applicant, Jean Alvarez, Brief interview was conducted with the Applicant.
It was learned that this facility will be licensed as a Residential Care Facility for the Elderly (RCFE) to serve up to 6 non-ambulatory clients. There were no clients present during today's pre-licensing visit.
Tour of the facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. COVID Precautions in place including signage, PPE storage and 30-day supply. Isolation rooms designated. COVID-19 Mitigation plan is in place. LPA observed no obstruction of emergency exits. Exit signs in place as appropriate. Fire extinguisher in various locations including kitchen, living room, laundry room, and outside area, and are fully charged. Facility map indicating emergency exits posted in appropriate locations. Complaint poster and Ombudsman Poster observed.
Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. Areas for sharp objects and toxins were secured with lock.

Medication cabinet, located in the kitchen area, was toured. First aid kit was observed to be present and contained all required components at this time.
A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the clients were observed to be sufficient and able to meet the needs of the clients at this time.
A tour of the resident bathrooms was conducted. {Cont. on 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: MOTHER MARY CARE HOME
FACILITY NUMBER: 392701157
VISIT DATE: 05/24/2022
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Hot water temperatures were taken and measured between 105-120*F.
Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time.
A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. A generator is in place in case of power outage.
This facility has been found to be in compliance at this time.
There were no deficiencies observed during today's Pre-licensing visit. Component III completed with applicant during visit. Exit Interview conducted with Jean Alvarez. A copy of this report was left with Jean.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2