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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701113
Report Date: 05/17/2023
Date Signed: 05/17/2023 10:26:23 AM

Document Has Been Signed on 05/17/2023 10:26 AM - 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: 1DATE:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Meireen Lamoca - AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Annual Inspection Visit. LPA Wallace. Department will conduct Post Licensing Visit in several months for facility.

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112.4 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Surety Bond: RSI Insurance Company - #LSM1560989 effective since September 11, 2021. Liability Insurance: NEK Insurance - $1,000,000/$3,000,000 for Aggregate/General Liability.

Fire extinguishers last inspected on 2/10/2023 and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication log. LPA reviewed one resident file and one staff file, including criminal record clearances. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. Fire drill was conducted on 5/16/2023 .

No deficiencies were cited during today's inspection. Exit interview and copy of report given to Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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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