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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 10/26/2022
Date Signed: 10/26/2022 05:20:11 PM


Document Has Been Signed on 10/26/2022 05:20 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:
10/26/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Jean AlvarezTIME COMPLETED:
05:20 PM
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On 10/26/22 at 4:15pm, Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a health and safety check. LPA Jensen met with Administrator Jean Alvarez and explained the purpose of today's visit.

LPA Jensen toured the facility including bathroom, two bedrooms, living room and basement/storage room. The temperature in the facility was set at 72 degrees which falls within the regulatory range of 68-85 degrees. The facility has implemented a water temperature log which was observed to be current through today. The water temperature readings were between the required regulatory range of 105-120 degrees. LPA Jensen observed 2 days of perishable food and 7 days of non perishable food on hand. The bathrooms were observed to have grab bars and non slip mats. The bedrooms were observed to be adequately furnished and the rooms were equipped with adequate lighting. LPA Jensen engaged with 2 of 4 residents during the course of the visit. Both residents stated they are well and satisfied with the facility. The facility has acquired a supply of clothing to keep on hand in the event that a resident comes to them without clothing. LPA Jensen also observed the facility to be sanitary and free of odor.

No deficiencies are being cited today from the California Code of Regulations (CCR) Title 22, Division 6.

An exit interview was conducted and a copy of this report was handed to the Administrator.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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