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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005503
Report Date: 09/20/2021
Date Signed: 09/20/2021 11:22:50 AM

Document Has Been Signed on 09/20/2021 11:22 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 #2FACILITY NUMBER:
397005503
ADMINISTRATOR:MARYANN PATACSILFACILITY TYPE:
735
ADDRESS:335 PRADO WAYTELEPHONE:
(209) 477-4915
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 6DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maryann PatacsilTIME COMPLETED:
11:30 AM
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On 9/20/2021 Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual Inspection at 10:15 with Designated Staff One (S1). LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 clients and today's census is 6. S1 accompanied LPA on facility tour. Licensee arrived shortly there after. Five of Five staff observed on site with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 11/29/2022. Prior to today's visit LPA contacted Licensee for COVID screening who confirmed no staff or clients have shown symptoms or tested positive in the past ten days.

LPA interacted with a random number of clients during this visit and observed clients. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed kitchen, garage, restroom, bedrooms, and common living areas to be clean and in good repair. LPA observed items stored including roof repair item from next door facility, Staff two (S2) immediately moved item to dumpster. LPA observed toxins, knives, centrally store medications stored inaccessible to clients. The temperature inside the facility was measured at 72*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 102*F not within regulatory range of is not less than 105*F and not more than 120*F. S1 immediately contacted Staff three (S3) to adjust the water heater who found it was turned to cold. Staff four (S4) stated they completed showers of 6 clients prior to LPA's entry. LPA remeasured hot water to be at 105*F at the end of the visit.

The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, but containing sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution.

Facility handles P & I monies, LPA observed the log is maintained correctly and there is no commingling of funds. LPA observed the facility conducts fire drills documented monthly.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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: MARYANN PATACSIL'S CARE HOME #2
FACILITY NUMBER: 397005503
VISIT DATE: 09/20/2021
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LPA observed fire extinguisher last inspected on 3/12/2021, pull alarm system, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap, touchless covered trash cans, and posted hand washing signs. 30 day supply of PPE stored off site with supplies available on site for staff.

Upon a file review the following items were discussed to be submitted with any changes to LPA by 10/8/2021:

Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Affidavit Regarding Client/Resident Cash Resources LIC400
Surety Bond LIC402
Emergency Disaster Plan LIC610D
First aid/CPR certificates

Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC809 (FAS) - (06/04)
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