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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700618
Report Date: 01/26/2022
Date Signed: 01/26/2022 01:02:32 PM

Document Has Been Signed on 01/26/2022 01:02 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: 34DATE:
01/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Marissa West - AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Ruth Wallace and Maja Jensen conducted an unannounced case management incident visit. LPA's met with Administrator and staff. LPA's interviewed Staff #1 regarding the incident on January 10, 2022. Incident involved C1 and C2 were in a physical altercation. During the earlier attempted visit, staff reported 32 clients and 16 staff tested positive on second response. LPA's did not do attempt to do 1 year annual inspection based on that information.

LPA's determined an incident report was not completed for CCL in a timely manner for the positive COVID-19 results for staff and clients.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, one deficiency was cited during this visit. See 809-D for deficiency cited. Failure to correct them by the noted due date may result in penalties being assessed.

Exit interview and copy of all reports were left with Administrator.


SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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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Document Has Been Signed on 01/26/2022 01:02 PM - It Cannot Be Edited


Created By: Ruth Wallace On 01/26/2022 at 12:36 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2022
Section Cited
CCR
80061(b)(1)E

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Reporting Requirements - 80061(b)(1)E
Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement is not met as evidenced by:
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Licensee agrees to submit a incident report regarding the positive clients and staff by POC of 1/31/31 via email to LPA.
maja.jensen@dss.ca.gov
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LPA's were at facility and COVID-19 positive staff and clients were not reported on a incident report to CCL by the seven day requirement. This poses a potential health, safety, and personal rights risk to residents in care
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022


LIC809 (FAS) - (06/04)
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