<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 05/08/2023
Date Signed: 05/08/2023 04:29:16 PM


Document Has Been Signed on 05/08/2023 04:29 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: 3DATE:
05/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jose AlvarezTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/8/23 at approximately 1:20pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a required 1 year annual inspection. LPAs Jensen and Fain met with care provider Jose Alvarez and explained the purpose of today's visit. The Licensee/Administrator Jean Alvarez is away and an LIC 308 assigning responsibility to Jose Alvarez in the Administrator's absence was received by the Department. The Administrator holds current Administrator's certificate # 6061970740.

LPAs Jensen and Fain toured the physical plant and grounds. The grounds were observed to be maintained and outdoor furniture in a shaded area is available for resident use. The facility currently has 3 residents in care. LPAs Jensen and Fain inspected the bedrooms, bathrooms, kitchen, staff quarters and common areas. The thermostat was set at 72 degrees for the comfort of residents in care. Knives, toxins, cleaning supplies were observed to be locked and inaccessible to residents in care. There are currently 2 bedrooms in use, both rooms are double occupancy. 2 of 2 residents bedrooms did not have lamps available. The bathrooms were equipped with grab bars in the shower and at the toilet. The water temperature in the main bathroom adjacent to the common area was measured at 115 degrees which falls within the required regulatory range of 105-120 degrees Fahrenheit. The facility maintains a 2 day supply of perishable food and a 7 day supply of non-perishable food. There is also an adequate supply of linens. The fire extinguisher was last serviced in April of 2023 and is in compliance. The carbon monoxide detector was tested and found to be in working order. The first aid kit was observed to be complete with scissors, tweezers, thermometer, various wound dressings and manual.

LPA Jensen reviewed 3 of 3 resident files and 2 of 2 staff files. 1 of 3 resident files were missing safeguards for personal property. 2 of 2 staff files were determined to be complete and in compliance. LPA Jensen interviewed 2 of 3 residents in care.

Continued on LIC 809C...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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 4


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: 05/08/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Jensen observed PRN medication and 2 disposable razors for a resident that has left the facility in late April of 2023 stored on top of a dresser in a resident bedroom. The resident bedroom where the PRN medication was found is a double occupancy room that is currently occupied by a resident. The PRN medications consisted of a variety of solutions, lotions and creams. LPA Jensen interviewed care provider Jose Alvarez who advised the PRN medication is pending destruction.

LPA Jensen requested a copy of the LIC 500 and current liability insurance emailed by 5/15/23 to maja.jensen@dss.ca.gov.

Deficiencies are being cited from the California Code of Regulations Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/08/2023 04:29 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: 05/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2023
Section Cited

1
2
3
4
5
6
7
Incidental Medical and Dental Care
...
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Licensee immediately locked all medications and agrees to email an attestation that this regulation has been read, understood and will be complied with by Plan of Correction due date.
8
9
10
11
12
13
14
Based on LPA Jensen's observation of PRN medication for a resident that has terminated services with the facility that was stored on top of a dresser and accessible to residents in care. This poses an immediate risk to the health, safety and perosnal rights of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/08/2023 04:29 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: 05/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2023
Section Cited

1
2
3
4
5
6
7
Personal Accomodations
Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement was not as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to place lamps in all resident rooms and ensure that lamps are accessible to residents in care. Licensee will consider using battery operated lamps if a resident has adverse behaviors related to electrical cords.
8
9
10
11
12
13
14
Based on LPA Jensen's observation of 3 of 3 residents missing a lamp from their bedrooms. This poses a potential risk to the health, safety and persobal rights of residents in care.
8
9
10
11
12
13
14
Type B
05/22/2023
Section Cited

1
2
3
4
5
6
7
Resident Records
....
Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agrees to complete a personal proeprty inventory for resident 1 and email to LPA at maja.jensen@dss.ca.gov by Plan of Correction due date.
8
9
10
11
12
13
14
Based on LPA Jensen's review of a resident file, Resident 1 did not have a personal property inventory completed upon admission or upon receipt of additional proeprty sent by family members. This poses a potential risk to the health, safety and personal rights of residents in care.
8
9
10
11
12
13
14
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: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4