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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700870
Report Date: 10/09/2023
Date Signed: 10/09/2023 05:35:32 PM


Document Has Been Signed on 10/09/2023 05:35 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:
10/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ralph Feril TIME COMPLETED:
04:00 PM
NARRATIVE
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On 10/09/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Representative (FDR), Ralph Feril and explained the purpose of this visit.

The purpose of this visit was in response to the annual visit conducted on 10/09/2023. It was learned during this visit that on 10/08/2023, R1 left the facility and walked down the street with Modesto Police Department at approximately 6:00pm.

LPA obtained R1's physicians report and learned that R1 is allowed out of the facility without assistance. It was learned that the facility has not provided a Special Incident Report to the department as of this date.

Based on interview and records review there were the following deficiencies that were cited during this case management visit.

A copy of this report was provided to the facility and an exit interview was conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 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)
Page: 1 of 2


Document Has Been Signed on 10/09/2023 05:35 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2023
Section Cited
CCR
87211(a)(1)(D)

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(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This is not met as evidenced by:
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Facility Administrator stated that a review of the section, 87211(a)(1)(D), will be conducted. A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at
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Based on interview and record review, the Licensee did not ensure that they have provided an incident report to the department after an incident that occured on 10/08/2023. This poses an potential health, safety, and personal rights risks to persons in care.
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arielle.pascua@dss.ca.gov. by the due date of 10/30/2023 COB. Information submitted must include attendees, trainers, and information discussed.

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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: Arielle PascuaTELEPHONE: 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)
Page: 2 of 2