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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701113
Report Date: 03/21/2022
Date Signed: 03/23/2022 02:23:13 PM

Document Has Been Signed on 03/23/2022 02:23 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:MGIL'S CARE HOME LLCFACILITY NUMBER:
502701113
ADMINISTRATOR:LAMOCA, MEIREEN I.FACILITY TYPE:
735
ADDRESS:2116 STARLIGHT DRIVETELEPHONE:
(408) 398-5951
CITY:MODESTOSTATE: CAZIP CODE:
95357
CAPACITY: 4CENSUS: 0DATE:
03/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Meireen LamocaTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA arrived and was granted entry to the facility by Applicant Meireen Lamoca.. An initial application to operate a Adult Residential Facility (ARF) was submitted to the Central Applications Unit (CAU) on 09/17/2021 for a capacity of four adult residents.

LPA Hurt observed the following:
Structure:
Facility is a one-story house with 4 resident bedrooms, 2 bathrooms, family / living room, dining area and kitchen. There is a 2-car garage attached in front of home. The resident bedrooms will accommodate residents' furnishings.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
Bedrooms #1-4 will accommodate 4 clients (each have their own bedroom)
Bathrooms:
All bathrooms have a working toilet, wash basin, and shower.
Linens and Hygiene Supplies:
Adequate supply of linens is stored in garage cabinet.
Emergency Phone Numbers, Exit Plan, and Sample Menu:
Will be posted and readily available for review in the living room.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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: MGIL'S CARE HOME LLC
FACILITY NUMBER: 502701113
VISIT DATE: 03/21/2022
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Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables would be stored in the kitchen and pantry.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems were hardwired and found operational.
Fire Extinguisher:
1 Fully charged and stored by front entrance near kitchen
Fire Clearance:
Approved on 01/18/2022
Appliances:
Electric four burner stove with oven, refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer are located in the laundry room in the hallways and were clean and noted to be operational.
Toxins:
Will be locked and stored under kitchen sink.
Water Temperature:
Tested and recorded at 108 degrees (within regulation)
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored in locked cabinet next to dining area. Medication will be stored and locked in cabinet next to dining area
Resident and Staff Files:
Records will be kept in filing area in living area.
Reading Material, Games, Equipment, & Materials:
The facility has materials that commensurate with their plan of operation.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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: MGIL'S CARE HOME LLC
FACILITY NUMBER: 502701113
VISIT DATE: 03/21/2022
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The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Unit.

Applicant was reminded of the statute that requires notification to Licensing Program Analyst within 5 business days of admitting the first resident. This notification may be done by phone, mail, email or fax.

At this time, facility has met all pre - licensing requirements of Title 22 division 6.

An exit interview was conducted with Licensee Meireen Lamoca and a copy of this report was provided at the time of visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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