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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 10/17/2022
Date Signed: 10/18/2022 09:04:36 AM

Document Has Been Signed on 10/18/2022 09:04 AM - 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: 5DATE:
10/17/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jose AlvarezTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Albert Johnson and Kesha Lewis arrived unannounced to conduct an annual inspection. LPA met with Jose Alvarez and explained the purpose of the visit. Later joined by Jean Alvarez.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, medication room, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 125.5 degrees Fahrenheit in resident bathroom sink, which is "not " within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. During the residents file review LPAs observed that R1 did not have medications for four days. R1 moved in on 10/13/22 and has not had his medication as prescribed.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, Deficiencies were observed and cited during this visit. Exit interview held with Administrator and a copy of report given at the conclusion of the visit.

Failure to submit Proof of Corrections (POC's) by plan of correction due dates may result in civil penalties.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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Document Has Been Signed on 10/18/2022 09:04 AM - It Cannot Be Edited


Created By: Albert Johnson On 10/17/2022 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MOTHER MARY CARE HOME
FACILITY NUMBER: 392701157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2022
Section Cited
CCR
80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies: (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.
(1) Hot water temperature shall be maintained at not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C
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Facility shall adjusted hot water temperature to not less than 105 degrees F and not more than 120 degrees F. LPA requested hot water temperature logs over the course of the next 3 days to clear the cited deficiency. Hot water logs are to provide proof that hot water is being maintained within the regulatory requirement.
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This requirement was not met as evidenced by hot water tested at 123.5 in the client's bathrooms. This is an immediate safety hazard.
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Type A
10/17/2022
Section Cited
CCR87465(c)(2)

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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.
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The Administrator has developed a plan on how the facility will follow the Physician's orders and document correctly when medications are missed. Please send the agenda along with the sign-in sheet for the in-service.
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This requirement is not met as evidenced by: Based on observation and records review, the Licensee did not ensure medications ordered for residents are given as prescribed which poses an immediate health and safety risk to residents in care.
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The facility will also report all incidents of medication errors, missed medication Etc.. to the resident's Primary Care Physician and to the department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


LIC809 (FAS) - (06/04)
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