<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700618
Report Date: 12/03/2021
Date Signed: 12/03/2021 12:11:08 PM

Document Has Been Signed on 12/03/2021 12:11 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MAR-RIC CARE HOMEFACILITY NUMBER:
502700618
ADMINISTRATOR:WEST, MARISSAFACILITY TYPE:
735
ADDRESS:2749 LINDBROOK DRTELEPHONE:
(209) 918-8061
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 38CENSUS: 36DATE:
12/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Marissa WestTIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12-3-21 at 10:08am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for incident reports dated 11-15-21, 11-20-21, 11-22-21, 11-24-1, and 11-25-21. LPA met with Administrator Marissa West and explained the purpose of the visit. LPA requested resident roster, staffing roster, staffing schedule for November, sign in and out policy, and plan of operation. LPA also interviewed Staff1 (S1) Administrator, and R1, R4, and R5. LPA also reviewed incident reports and physician reports with Administrator. Based on incident reports received, Resident1 (R1) exited facility on 11-15-21 and was placed in county mental health on 11-19-21. Interview with Administrator confirmed 51/50 hold for R1 was due to exit seeking behaviors and attempts to enter nearby neighbors' homes. R2 exited facility on 11-24-21 at approximately 5:00pm and 9:20pm and is currently residing in mental health. R3 exited facility on 11-20-21 at approximately 12:30pm and is residing at facility.

Based on record review, it is determined that R1, R2, and R3 are able to leave facility unassisted. Further record review reveals facility has an action plan for missing clients including procedures for notifying Administrator, Sheriff's department, responsible person, and case manager for follow up and necessary intervention. Staff training includes procedures for absence without leave (AWOL), and mental health diagnoses. Facility is following appropriate procedures according to written AWOL policy and action plan. Staff is receiving training on AWOL preventions due to previous incident reports submitted.

As a result of today's visit, no deficiencies are cited. An exit interview was conducted with Marissa West and a copy of this report was left with Marissa.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1