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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803929
Report Date: 07/27/2021
Date Signed: 07/27/2021 01:58:45 PM

Document Has Been Signed on 07/27/2021 01:58 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MAGGIE'S CARE HOMEFACILITY NUMBER:
496803929
ADMINISTRATOR:GARCIA, MAGGIEFACILITY TYPE:
740
ADDRESS:916 RENEE COURTTELEPHONE:
(707) 293-9833
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Heherson Garcia & Maggie Garcia, AdministratorsTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Lopez conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff and later met with administrators, Heherson Garcia and Maggie Garcia. LPA conducted a Risk Assessment call prior to the visit. There were 5 residents in care present at the facility all which have dementia.

LPA arrived at the facility and had temperature checked and signed in on a sheet. During the tour facility was found to be clean and at a comfortable temperature. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on March 1, 2021. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. There was sufficient amount of supply for both perishable and nonperishable foods as required. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available.

Continued on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: MAGGIE'S CARE HOME
FACILITY NUMBER: 496803929
VISIT DATE: 07/27/2021
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Facility has submitted a mitigation program plan that has been approved on 1/21/2021. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Staff and residents are being monitored 2x/day and results are documented. Facility has a suffiicent supply of PPE and excess supplies stored in the garage. Facility has a 30-day supply of medication for residents. Residents do not typically wear masks inside the facility but have them available.

No deficiencies cited during today's Required 1- Year inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC809 (FAS) - (06/04)
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