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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203028
Report Date: 06/28/2023
Date Signed: 06/28/2023 01:08:26 PM

Document Has Been Signed on 06/28/2023 01:08 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MARCI MEDINA'S CARE HOMEFACILITY NUMBER:
397203028
ADMINISTRATOR:MEDING, CINDY R.FACILITY TYPE:
735
ADDRESS:2449 NEW BRIGHTON LANETELEPHONE:
(209) 451-1158
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 0DATE:
06/28/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:CINDY MEDINATIME COMPLETED:
01:30 PM
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On 6/28/2023 at 10:30am, Licensing Program Analysts (LPAs) Jennifer Fain and Kesha Lewis arrived at this facility announced to conduct an annual inspection visit. LPAs met with the Administrator Cindy Medina and explained the purpose of the visit.

LPAs Fain and Lewis inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathroom, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an ARF facility with a current census of 0. Facility has 3 bedrooms and 1 bathroom for resident use. Facility has a dining area off of the kitchen and a formal living room. Facility currently has no residents.

Water temperature reads 119.3 which is within the regulated temperature of 105*F to 120*F and room temperature reads 70 degrees Fahrenheit. LPAs observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were sanitary and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were serviced 6/7/2023 and are in compliance. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. Facility has appropriate internet access available for resident use. Facility’s liability insurance is current and up to date per regulatory requirements. LPAs reviewed facility’s disaster plan to ensure regulatory compliance.

Administrator's Certificate was observed to be current through 3/29/24.

Continued on LIC 809C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MARCI MEDINA'S CARE HOME
FACILITY NUMBER: 397203028
VISIT DATE: 06/28/2023
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LPA Lewis requested a phone update and will send form. Administrator will email Form with correction to kesha.lewis@dss.ca.gov

The Inspection Tool was used for this visit.

The facility was found to be in substantial compliance. An exit interview was held and a report was given to Administrator Cindy Medina.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
LIC809 (FAS) - (06/04)
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