502700870-10-5-2020-27-AS-AMAZ-BU524H-20201005170357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700870
Report Date: 10/05/2020
Date Signed: 10/05/2020 05:04:24 PM

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:	MARGARET'S CARE HOME		FACILITY NUMBER:	502700870
ADMINISTRATOR:	FERIL, MARGARET F.		FACILITY TYPE:	740
ADDRESS:	2208 TEMESCAL DRIVE		TELEPHONE:	(209) 482-5411
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 0	DATE:	10/05/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Margaret Feril		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to commence a virtual pre-licensing Inspection visit on 10/05/2020 due to COVID-19 and pre-cautionary measures. LPA Martinez identified herself and discussed the purpose of the call and the elements of the pre-licensing visit with Margaret Feril

The facility has a fire clearance for 6 residents: 1 non-ambulatory resident and 5 ambulatory residents. Margaret will be the administrator of this facility. The facility administrator’s certificate #:6054358740 and expires on: 12/05/2021.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. The facility was virtually toured both indoor and outdoors with Margaret Feril.

Physical Plant: The interior of the facility is sanitary. The facility living room, common areas, laundry room, activities room, and bathrooms are furnished. Facility beds are not equipped with mattress protectors. The facility has a public telephone. The facility has 2 fire, which expire on 09/20/2021. The facility is equipped with smoke detectors and carbon monoxide detectors. The facility water temperature is 110 degrees. The facility room temperature is 78 degrees. The exterior of the facility is clean and clear of debris. The backyard patio area is furnished, and is located in a shaded area. The exterior fire clearance door is in good repair.

Food Services: The facility has the required two day perishable and 7 day non- perishable food supply. The kitchen area is equipped with utensils, plates, and bowels. The kitchen has locked cabinets for sharp utensils. The facility has emergency food and water. Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MARGARET'S CARE HOME	FACILITY NUMBER: 502700870
	VISIT DATE: 10/05/2020

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Care & Supervision: At this time, the facility does not have any residents.

Records Review: The facility has a staff and resident file process. The facility has resident and employees' files set up. The facility does not have a fire drill manual. The facility does not have fire drill log. The facility does not have an emergency kit and manual.

Medication: The facility has a locked medication cabinet with a first aid kit. Each resident does not have a medication storage container. The facility will be using the centrally stored medication Log form to record medication.

The applicant has not passed the pre-licensing component of the application process. This facility is currently licensed under another name and licensee. LPA Martinez will follow up with licensing issue.

Items needed

Fire Drill Log
Medication storage container for each resident
Emergency Kit & Manual
Mattress protector
Licensing issue- Facility already licensed to another licensee.

Exit Interview conducted and 809 report was emailed to the administrator. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020

LIC809 (FAS) - (06/04)

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