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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 12/12/2023
Date Signed: 12/12/2023 01:34:25 PM


Document Has Been Signed on 12/12/2023 01:34 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:
12/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Jean Alvarez - Licensee/AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace arrived unannounced to conduct a case management visit. LPA met with Licensee/Administrator. Administrator holds current Administrator's certificate # 6061970740 which expires March 13, 2024.

LPA and Licensee 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 four residents in care. LPA inspected the bedrooms, bathrooms, kitchen, staff quarters and common areas. The thermostat was set at 74 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 three bedrooms in use, one room has double occupancy. The other two rooms are private occupancy. 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 110.3 degrees which falls within the required regulatory range of 105-120 degrees Fahrenheit. The facility maintains a two day supply of perishable food and a seven day supply of non-perishable food. There is also an adequate supply of linens. The fire extinguisher was last serviced on April 6, 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 reviewed three resident files and three staff files. All resident and staff files were determined to be complete and in compliance. Medication Management including destruction of Medication and PRN’s was reviewed. All records in compliance.

No deficiencies are being cited from the California Code of Regulations Title 22, Division 6.
An exit interview was conducted with licensee. A copy of this report and LIC 811 (Confidential Names).
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
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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