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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803929
Report Date: 09/07/2023
Date Signed: 09/07/2023 11:05:16 AM


Document Has Been Signed on 09/07/2023 11:05 AM - 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:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Heherson Garcia (Licensee)TIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensees, Heherson and Maggie Garcia. Required postings were observed. During today's visit residents were observed participating in activities.

LPA/Licensee initiated a tour of the facility around 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Hot water temperature in bathrooms used by residents measured at 105.3 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Fire extinguisher was last serviced April 2023. Smoke detectors and carbon monoxide detector in the hallway was tested and properly working. Last disaster drill conducted on 7/19/23. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Administrator Certificate for Heherson Garcia, 6053168740, expires on 12/2/23. Medications were reviewed, centrally stored and locked. Emergency supplies were observed.

LPA initiated file review at 10:00 am. LPA reviewed six residents files and four staff files. All residents files does have a current medical assessment and care plans were signed by their responsible party within the last 12 months. Staff records have current First Aid/CPR certificates and additional 20 hours of required training.

Licensee agreed to submit updates of the following documents by 9/15/23: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan & Copy of Liability Insurance.

No deficiencies cited during today's visit.

Exit interview was conducted with Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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