502700870-10-9-2023-27-AS-APAA-CWFTEK-20231009144005

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700870
Report Date: 10/09/2023
Date Signed: 10/09/2023 02:40:49 PM

Document Has Been Signed on 10/09/2023 02:40 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 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: 6	DATE:	10/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Ralph Feril		TIME COMPLETED:	02:40 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 10/09/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member, Antoinette Garcia, and explained the purpose of the visit. LPA Pascua asked that SM Garcia call the Facility Designated Administrator, Margaret Feril, to inform them that CCL was present. It was learned at this time that FDA Feril was unable to come to the facility at this time. Shortly after, LPA met with Facility Designated Representative, Ralph Feril and explained the purpose of this visit. There were no other staff members present at this time. Current census was 6. A brief interview with FDR Feril was conducted. This facility is licensed to serve 6 residents, 5 of which are ambulatory and 1 non-ambulatory. This facility has a dementia plan on file and has a hospice waiver for 3. It was learned that only the administrator and the representative have access to the facility files. LPA explained that facility records must be made available at all times to CCL staff. LPA reviewed 3 resident files and 3 staff files. Administrator has a current administrator certificate #6054358740 and expires on 12/05/2023. A medication cabinet was identified in the kitchen. Along with the FDR Feril, LPA observed, reviewed, and compared medication to medication dispensing logs. First Aid Kit was present and contained all of the required components. Fire Extinguisher was in compliance and has been services by Hayden Fire Protection on 07/13/2023. 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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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: 10/09/2023

NARRATIVE

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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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/09/2023 02:40 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: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section comply with the section cited above in by not ensuring that the current staff members do not have a current First Aid/CPR certificate. It was observed that First Aid certificate has expired on 06/30/2021 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Licensee shall provide a statement of acknowledgement of above Section. Staff who do no thave current First Aid/CPR certificates shall obtain certification by POC date. A copy of current First Aid/CPR shall be provided to the LPA by POC date.

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section above in by not ensuring that S1 did not have a criminal record clearance prior to working at the facility which poses an immediate health, safety and personal rights risks to persons in care.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Licensee shall provide a statement of acknowledgement of above section. Licensee shall obtain criminal record clearance from the department. An immediate $500 civil penalty will be assessed.

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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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