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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700618
Report Date: 04/11/2024
Date Signed: 04/11/2024 01:28:32 PM

Document Has Been Signed on 04/11/2024 01:28 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: DATE:
04/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Jaime AndradeTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on 04/11/2024 at 12:48 PM. LPA Martinez met with Jaime Andrade to explain the purpose of the visit.

The purpose of the visit is to follow up on an incident report received on 04/11/2024. LPA Martinez reviewed client 1 (C1) and client 2 (C2) facility files. In addition, LPA Martinez obtained copies of client records, and reviewed video footage of client on client incident. Moreover, Community Care Licensing Department received an incident report and Law enforcement was called. At this time, both clients are out of the facility, and there are no immediate health and safety risks at the facility.

LPA Martinez will continue to follow up on this incident. An exit interview was conducted, and copy of this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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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