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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005502
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:31:12 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/01/2022 11:31 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:MARYANN PATACSIL'S CARE HOME #1FACILITY NUMBER:
397005502
ADMINISTRATOR:MARYANN PATACSILFACILITY TYPE:
735
ADDRESS:329 PRADO WAYTELEPHONE:
(209) 477-5219
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 6DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maryann MasayaTIME COMPLETED:
11:45 AM
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On 11/1/22 at 9:30am Licensing Program Analyst (LPA) Maja Jensen and LPA Kesha Lewis arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Licensee Maryann Masaya and explained the purpose of today's visit. Licensee Maryann holds a current Administrator certificate good through 11/24/24.

LPA Jensen toured the facility including but not limited kitchen, dining room, living room, 3 client bedrooms, garage and grounds. The facility is a single story structure with 3 double occupancy rooms for clients and a live in staff bedroom. The facility was observed to be sanitary and free of odor. The facility was equipped with adequate furniture and lighting for the 6 clients. During the course of the visit LPA Jensen engaged with 2 of 2 clients that were present. The remaining 4 clients were at day program.

There is a single main entrance with all required signs posted. A thermometer for COVID screening and sign in logs were observed at the facility entrance. The facility has in excess of a 30 day supply of PPE. The emergency disaster plan was reviewed and found to be in compliance. The facility conducts monthly fire drills which are logged. The fire alarm and carbon monoxide detector was tested and found to be in good working order. The facility was observed to have several first aid kits. The first aid kits were observed to be complete with tweezers, scissors, thermometer and various wound dressings.

Medication was observed to be locked and inaccessible to residents. Toxins and cleaning supplies were observed to be locked and inaccessible to residents. Knives and sharp objects were also observed to be locked and inaccessible to residents in care. The facility maintains an ample supply of linens. The bathrooms were observed to be equipped with grab bars at the shower and toilet. Non-slip mats were available for the bathrooms.

Continued on LIC 809C....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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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: MARYANN PATACSIL'S CARE HOME #1
FACILITY NUMBER: 397005502
VISIT DATE: 11/01/2022
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The facility was observed to have in excess of a 2 day supply of perishable food and 7 day supply of non-perishable food. A random sample of non-perishable food was checked and no expired food was observed. Tuna sandwiches were being prepared for lunch which is consistent with what was posted on the menu.

Staff present at the facility during the course of the visit were observed to have criminal background clearance and were associated to the facility. There was one direct care provider present during the course of visit who's file was reviewed and determined to be complete with all necessary certifications and documentation. The resident files for the 2 residents present during the course of the visit were reviewed and found to be complete. P&I file records were checked in the presence of and together with the Licensee. The accounting for P&I funds was determined to be accurate. Medication Records were reviewed and determined to complete.

The grounds were observed to be well maintained and free of obstruction. There are no bodies of water on the property.

LPA Jensen requested the following records in order to update the regional office master file:
Control of Property
Liability Insurance
LIC 500

The Licensee emailed proof of insurance and provided a copy of the property grant deed to LPA Jensen. The Licensee will email an updated LIC 500 to LPA Jensen by close of business 11/4/22.

No deficiencies were cited on this day from the California Code of Regulations or the Health and Safety Code.

An exit interview was conducted and a copy of this report was handed to the Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
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