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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803929
Report Date: 06/27/2022
Date Signed: 06/27/2022 01:20:33 PM


Document Has Been Signed on 06/27/2022 01:20 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:MAGGIE'S CARE HOMEFACILITY NUMBER:
496803929
ADMINISTRATOR:GARCIA, HEHERSON MFACILITY TYPE:
740
ADDRESS:916 RENEE COURTTELEPHONE:
(707) 293-9833
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 6DATE:
06/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Heherson & Maggie Garcia (Licensees)TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Cuadra arrived at the facility for the purpose of conducting an unannounced Case Management visit and follow up on items that were concerning and ensure compliance with Informal conference conducted on 6/3/22. LPA was greeted at the door by staff and Licensees Heherson and Maggie Garcia arrived later.

During today's visit, LPA observed six residents in care at the facility. LPA observed two facility staff on duty assisting residents with their lunch. LPA learned through records review, observations and interviews with Licensee that seven out of seven facility staff have CPR, 1st Aid certifications, initial training 40 hours and vaccination records which includes 100% vaccination rate for residents and staff. LPA reviewed incident report logs that confirmed that facility has been reporting incidents to CCL within regulations. Per Licensee, after continuous incidents of elopement from one of the residents, they decided to install four cameras as which are positioned in the living room, outside and inside front door and inside in the sun room. The cameras are on and have a motion sensor to detect movement only. The Licensee is required to update the facility's plan of operation when a new service is added and will elaborate an addendum to the resident's admission agreements. Licensee was given instructions of the Guidelines for Video Surveillance to assist in developing a policy. Licensee stated the cameras would be turned off at this time and would be reinstalled until a Video Surveillance policy is created.

No deficiencies were observed or cited during today's Case Management visit. Exit interview was conducted and a copy of this report was provided to the facility Licensee, Heherson Garcia.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
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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