<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700870
Report Date: 09/21/2022
Date Signed: 09/21/2022 05:07:44 PM


Document Has Been Signed on 09/21/2022 05:07 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: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:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ralph FerilTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/21/2022 at 1:30pm, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a infection control visit. LPA Pascua met with staff member, Ralph Feril and explained the purpose of this visit. LPA Pascua asked staff member, Feril to call the Administrator, Margaret Feril, to let her know that CCL is present at this time. This facility is licensed to hold 6 residents with a hospice waiver for 3.
At 1:40pm, LPA Pascua initiated a tour of the facility with staff member, Ralph Feril.
Current Census is 6.
Administrator has a current certificate and expires on 12/05/2023. Fire extinguishers located in the kitchen and hallway have been inspected by Hayden Fire Protection on 07/15/2022.
This facility has a central screening point and have a sufficient amount of PPE supply.
The kitchen area was toured. LPA identified non-perishable and 2 days perishable food supply. Knives were observed to be locked in the kitchen cabinet and made inaccessible to the residents at this time.
A medication cabinet was identified in the kitchen. LPA observed medication to be pre-poured from designed resident bottles to another medication dispenser. Staff member stated that this is easier for them to disperse medication. LPA Pascua advised staff member, Feril what the regulations are about pre-pouring medication. Along with the staff member, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.
A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.
Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the garage was conducted. Additional non-perishable food supplies were identified. All cleaning supplies were locked and made inaccessible to residents at this time.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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 4


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: 09/21/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.



Appeal rights were printed and a copy was given to the facility .

Exit Interview.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/21/2022 05:07 PM - It Cannot Be Edited

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: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
87465(h)(5)
Each residents medication shall be stored in its original recieved contrained. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in LPA observed medication to be pre-poured into 2 other medication dispensers prior to providing it to the 6 out of 6 residents which poses an immediate health, safety, or personal rights risks to the persons in care.
POC Due Date: 09/22/2022
Plan of Correction
1
2
3
4
Licensee will stop pre-pouring medication and leave it in it's intended bottle. Licensee agrees to read and fully understand the regulation provided by the LPA. Licensee will conduct further training for all employees and send in a copy of the training and sign in sheet to the LPA by 09/22/2022 POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/21/2022 05:07 PM - It Cannot Be Edited

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: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303(a) Maintanence and Operation
The facility shall be clean, safe, and sanitary and in good repair at all times. Maintenance shall include provision of maintanence services and procedures for the safety and well-being of residents, employees, and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in by LPA observed the backyard to be unmaintained and has an overgrowth of plants which poses a potential health, safety, or personal rights risks to the persons in care.
POC Due Date: 10/12/2022
Plan of Correction
1
2
3
4
Licensee agrees to landscape the backyard and clear any hazards present and send in a picture to the LPA's email by 10/12/2022.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4