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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800471
Report Date: 05/19/2023
Date Signed: 05/19/2023 03:49:36 PM

Document Has Been Signed on 05/19/2023 03:49 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MARGARETS FAMILY HOMEFACILITY NUMBER:
486800471
ADMINISTRATOR:MROZ, MARGARETFACILITY TYPE:
735
ADDRESS:566 FIESTA CT.TELEPHONE:
(707) 421-0714
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 2DATE:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Margaret Mroz, AdministratorTIME COMPLETED:
05:03 PM
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Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and met with Margaret Mroz, Administrator.

LPA toured the facility, which was at a comfortable temperature; all exits were unobstructed. Staff have CPR/First Aid certifications. Fire extinguishers were charged and serviced 03/15/2023. LPA reviewed staff and client files. 2 of 2 client bedrooms were fully furnished per regulation. Cleaning solutions and disinfectants were observed locked. Liquid hand soap and paper towels are available in bathrooms. Facility food supply was within regulation and accessible to clients. Medication was centrally stored and locked. The facility has an in-ground pool located in the backyard, which was inaccessible/blocked with an iron fence and observed locked.

LPA requested the following updated forms to be submitted to Community Care Licensing by 06/19/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Surety Bond
· LIC 610E Emergency Disaster Plan
· Copy of current Administrator's Certificate

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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