392701157-6-20-2023-27-AS-MJEN-CSYNPV-20230620103857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 06/20/2023
Date Signed: 06/20/2023 10:39:24 AM

Document Has Been Signed on 06/20/2023 10:39 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 HOME		FACILITY NUMBER:	392701157
ADMINISTRATOR:	ALVAREZ, JEAN		FACILITY TYPE:	740
ADDRESS:	492 E. FRISBEE LANE		TELEPHONE:	(209) 888-4080
CITY:	FRENCH CAMP	STATE: CA	ZIP CODE:	95231
CAPACITY:	6	CENSUS:	DATE:	06/20/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jean Alvarez		TIME COMPLETED:	10:00 AM

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On 6-20-23 at 9:00am, a meeting was held with licensee to discuss a Technical Support Program Engagement Summary (TSP) generated on 05/25/2023. This meeting was held virtually via Teams Meeting. Present at this meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Maja Jensen, LPA Jennifer Fain, and Ombudsman Kathryn Thomas. At the beginning of the meeting, Licensee confirmed receipt of TSP material from virtual visits on 2/7/23, 2/23/23 and 3/2/23 as well as the on site visit from 2/23/23.

LPM and LPA discussed the following topics previously addressed at the TSP Engagement:

· Client assessments update requirements

· Licensee generated system to track specific files requiring updates

· Use of CARE tools to aid in maintaining compliance

· Communication with LPA to preemptively address discovered issues and resolutions

· Assessment procedures to ensure staff are able to meet needs of clients

· Reporting requirements such regulatory requirements and what constitutes an incident report

· Medication Management including destruction of Medication and PRN’s

Continued on LIC 809C....

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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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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: 06/20/2023

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Continued from LIC 809...

The Licensee has agreed to the following:

A medication audit to be completed by the 6/30/23 with audit results submitted to LPA Maja Jensen at maja.jensen@dss.ca.gov.

Submission of the Needs and Service Plan tracking system currently in place to be submitted to LPA Maja Jensen at maja.jensen@dss.ca.gov by 6/30/23

A medication training refresher for all staff to be completed within 90 days

A Reporting Requirements training refresher for all staff to be completed within 90 days

No citations issued today. An exit interview was conducted with Jean Alvarez and a copy of this report was emailed to Jean with a request to return with signature to maja.jensen@dss.ca.gov.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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