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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 05/21/2024
Date Signed: 05/21/2024 01:01:59 PM


Document Has Been Signed on 05/21/2024 01:01 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: 4DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:JEAN ALVAREZ - ADMINISTRATORTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Inspection Visit. LPA met with administrator and explained the purpose of the visit. Administrator Certificate expires 10/26/2025.

LPA and administrator toured the physical plant including resident bedrooms, resident bathrooms, and property area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.
LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 111.9 degrees Fahrenheit in kitchen sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers last inspected 4/1/2024. LPA checked medication storage and found medication to be locked away and inaccessible to residents. First aid kit was checked and is complete. Emergency and disaster drill conducted on 5/1/2024.

LPA reviewed four resident files and three staff files, including criminal record clearances. A review of staff records indicates that all staff or other individuals who require caregiver background checks are Fingerprint cleared and but staff 2-3 are not associated or transferred to the facility. Licensee will have staff get fingerprint cleared today and send documentation to LPA Wallace when cleared. LPA verified staff training for staff file reviews.

LPA requested the following updated documents for community care licensing to be submitted via email by May 28, 2024: LIC 308 Designation of Administrator, LIC 500 - Personnel Report, Copy of Administrator's Certificate, and Copy of Liability Insurance with expiration date. ruth.wallace@dss.ca.gov
Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, see 809-D for deficiency observed or cited today. Immediate civil penalty issued on today's date for both staff. Failure to correct deficiency may result in the additional civil penalties.
Exit interview conducted with administrator. A copy of report and LIC 811 (Confidential Names) left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
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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Document Has Been Signed on 05/21/2024 01:01 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in staff 2-3 have fingerprint clearances for other facilities and were not transferred to current facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee agrees to have both staff fingerprint cleared today and will send documentation of clearances to LPA Wallace by Plan of Correction date of 5/29/2024. Immediate civil penalty of $500.00 issued on today's date. Licensee agrees to scan documents and submit via email: ruth.wallace@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
LIC809 (FAS) - (06/04)
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