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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700618
Report Date: 08/14/2024
Date Signed: 08/14/2024 11:11:02 AM

Document Has Been Signed on 08/14/2024 11:11 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
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: 37DATE:
08/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Marissa West TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst, Kesha Lewis arrived on [month day, year] for an unannounced inspection to follow up on a self-reported incident which resulted in a case management visit. LPA explained the purpose to the staff and administrator, WEST, MARISSA

On 04/11/2024, the facility reported to CCL that a resident was stabbed by another resident. The Department has concluded an analysis of the incident which included interviews with staff, residents, the administrator, and Stanislaus County sheriff’s department and has determined that Mar-Ric Care home failed to verify that R2'S Physician’s Report was completed and documented, “able to leave facility unassisted”, resulting in R2 leaving the facility unsupervised, obtaining a dagger and stabbing R1 in the chest.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. A civil penalty in the amount of $500 is being issued on today's visit for Neglect/Lack of Care and Supervision which resulted in R1 assessing the community without supervision, obtaining a dagger and using it to injure another resident. Failure to correct the deficiency may result in additional civil penalties. At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1548(f)(1)(A). Appeal rights were provided. Exit interview conducted with WEST, MARISSA. Copy of the report was provided to the Administrator WEST, MARISSA and appeal rights were received.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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 08/14/2024 11:11 AM - It Cannot Be Edited


Created By: Kesha Lewis On 08/12/2024 at 09:00 AM
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: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/14/2024
Section Cited
CCR
85078(a)(1)

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85078 - Responsibility for Providing Care and Supervision
a) In addition to Section 80078, the following shall apply:
(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
This is evedinced by:
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Licensee stated they will review Physician’s Report and update care plans for each resident and review them with staff to ensure all needs are met. Licensee to hold the review training with all staff. Licensee to send copies of training sign in sheet along with staff schedule to LPA by POC due date.
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Based in File revies and interviews Mar-Ric Care home failed to verify that R2'S Physician’s Report was completed and documented, “able to leave facility unassisted”, resulting in R2 leaving the facility unsupervised, obtaining a dagger and stabbing R1 in the chest. This Poses a immiateate risk for resients on care.
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Deficiency Dismissed
Type A
08/19/2024
Section Cited
CCR80064(a)(2)

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Administrator - Qualifications and Duties
(a) The administrator shall have the following qualifications: (2) Knowledge of the requirements for providing the type of care and supervision needed by clients, including ability to communicate with such clients.
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The Licensee will send an attestation by email to Kesha.Lewis@dss.ca.gov by 8/19/24 that licensee understands regulation.
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Based on records reviewed the facility failed to create a plan to prevent R2 from bringing items into the facility that could be dangerous. This poses an immediate risk to the health, safety and personal rights of 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:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


LIC809 (FAS) - (06/04)
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