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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005503
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:50:07 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/01/2022 02:50 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: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: 4DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maryann MasayaTIME COMPLETED:
03:00 PM
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On 11/1/22 at 1:00pm 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 Administrator Maryann Masaya and explained the purpose of today's visit. Maryann holds a current Administrator certificate good through 11/24/24.

LPA Jensen toured the facility including but not limited to the kitchen, dining room, living room, 3 client bedrooms, garage and grounds. The facility is a single story structure with 2 single occupancy and 1 double occupancy room 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 4 clients. During the course of the visit LPA Jensen engaged with 4 of 4 clients that were present.

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 fire extinguisher was last serviced in March of 2022 and is in compliance. 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. The thermostat was set at 70 degrees Fahrenheit for the comfort of the residents. The water temperature in the kitchen was measured at 110.5 degrees Fahernheit which falls within the required regulatory range of 105-120 degrees. 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 #2
FACILITY NUMBER: 397005503
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. Tuna sandwiches were served 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 two part time direct care providers employed by the facility who's file was reviewed and determined to be complete with all necessary certifications and documentation. The resident files for 4 of 4 residents were reviewed and found to be complete. P&I file records were checked and the accounting for P&I funds was determined to be accurate. Medication Records were reviewed and determined to complete. Medication bubble packages were compared against the Medication Administration Record (MAR) and found to be accurate.

The grounds were observed to be well maintained and free of obstruction. There is patio furniture in the backyard for use by the residents. 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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