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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700618
Report Date: 01/29/2025
Date Signed: 01/29/2025 08:08:03 PM

Document Has Been Signed on 01/29/2025 08:08 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MAR-RIC CARE HOMEFACILITY NUMBER:
502700618
ADMINISTRATOR/
DIRECTOR:		WEST, MARISSAFACILITY TYPE:
735
ADDRESS:2749 LINDBROOK DRTELEPHONE:
(209) 869-2848
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 38CENSUS: 38DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Marissa West and Jaime AndradeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Unannounced annual visit made out to this day program on 01/29/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Marissa West, and was briefly interviewed.
Current census was 38 residents.
It was learned that there weren't any residents under the care of hospice at this time.
It was learned that there weren't any residents diagnosed with dementia at this time.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Marissa West. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 07/26/2025 with certificate # 7002224735.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinets and supplies, located in the facility medication room, were toured and reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the present facility designated medication personnel at this time. This medication room was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Linen closet, located in the laundry room, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MAR-RIC CARE HOME
FACILITY NUMBER: 502700618
VISIT DATE: 01/29/2025
NARRATIVE
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Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 09/24/2024 by the local fire extinguisher company, Jorgensen Co. and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (7) facility resident records was conducted and noted on the following LIC 858 form.
A review of (7) facility staff records was conducted and noted on the following LIC 859 form.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2025 08:08 PM - It Cannot Be Edited


Created By: Charlie Yang On 01/29/2025 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MAR-RIC CARE HOME
FACILITY NUMBER: 502700618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the hot water that was measured in one of the resident restroom faucets delivered hot water at 123.3 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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The facility designated Administrator stated that the hot water heater will be immediately turned down. The hot water will be measured at various intervals throughout the day for the next (7) days. A statement of correction, along with the (7) days worth of measurements, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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