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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700870
Report Date: 10/04/2021
Date Signed: 10/04/2021 12:50:28 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 HOMEFACILITY NUMBER:
502700870
ADMINISTRATOR:FERIL, MARGARET FFACILITY TYPE:
740
ADDRESS:2208 TEMESCAL DRIVETELEPHONE:
(209) 482-5411
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 6DATE:
10/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Margaret Feril, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA met with Margaret Feril, Administrator

LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.
LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature at 114.4 degrees in residents bathroom and room temp at 79 degrees.
Fire Drill conduced. Fire extinguisher maintained 7/1//2021. Fire alarm and carbon monoxide functional. LPA observed sharps and toxins locked.

LPA reviewed 3 staff and resident files. Resident emergency contact complete. LPA observed all staff files complete. Administrator Certificate valid until 12/5/21.
All persons in facility fully vaccinated. LPA observed 30 days PPE supply.

LPA and AD observed centrally stored medications. LPA and AD observed the lock on one of the medication cabinets not functioning.

Upon entry, AD did not conduct symptom check until requested by LPA. Sanitizer/ thermometer were observed. Sign in sheets were observed to document date and visitors name. Sign in sheets did not include symptom screening for reporting requirements to public health officer and contact tracing.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2021
Section Cited

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This regulation was not met by evidence by:
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Based on observation: Licensee did not ensure cabinet that holds medications was locking properly making the medications accessible to the residents in care. This poses an immediate risk to the residents.
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Licensee will send a letter acknowledging the undestanding of the regulation and a picture showing the lock has been repaired by POC date.
Type B
10/15/2021
Section Cited

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87464 (f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).This regulation was not met by evidence by:
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Based on observation, Licensee did not have a sign-in policy available upon entry to ensure compliance with symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing).
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2021
LIC809 (FAS) - (06/04)
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