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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 02/03/2023
Date Signed: 02/07/2023 01:48:44 PM


Document Has Been Signed on 02/07/2023 01:48 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/07/2023 07:26 AM

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

NARRATIVE
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On 2/3/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management health and safety check related to fire clearance. LPA Jensen met with Jose Alvarez, care giver, and explained the purpose of today's visit. LPA Jensen called Licensee on teh telephone and there was no answer. LPA Jensen left licensee a voicemail.

LPA Jensen observed the thermostat in the facility to be set at 67 degrees which is below the required regulatory range of 68-85 degrees. LPA Jensen observed 4 of 4 residents at the facility. 2 of 4 residents were asleep and 2 of 4 residents interviewed advised they were satisfied with the care being received.

LPA Jensen inquired about the status of the fire clearance. LPA Jensen was advised that the fire department came out and gave the approved the clearance but did not leave a coy of the paperwork .

LPA Jensen received a phone call during the course of the visit from the Licensee. LPA Jensen spoke to Licensee Jean Alvarez who advised that the Fire Marshal stated he would email licensing the clearance on Monday and she assumed Community Care Licensing was in possession of the clearance. LPA Jensen advised no such email was received. **This report is being amended to reflect that the fire clearance was granted for 2 bedridden clients prior to the writing of this report therefore the civil penalty is withdrawn**

Deficiencies are being cited form the California Code of Regulations (CCR) Title 22, Division 6.

An exit interview was conducted and a copy of this report with appeal rights was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
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


Document is an Amendment of Original Document on 02/07/2023 07:29 AM

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: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2023
Section Cited

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Maintenance and Operation
(b) A comfortable temperature for residents shall be maintained at all times.

(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).
This requirement was not met as evidenced by:
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The Licensee will send an attestation that the regulation has been read, understood and will bve complied with at all times by the POC due date
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 This requirement was not as evidenced by LPA Jensen's observation of the facility thermostat temperature reading of 67 degrees upon arrival. This poses a potential health, safety and personal rights risk to residents in care.
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Type B
02/04/2023
Section Cited

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Intentionally left blank
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2