502701113-7-15-2025-27-AS-ELIM-DJLQPT-20250715122115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701113
Report Date: 07/15/2025
Date Signed: 07/15/2025 12:21:29 PM

Document Has Been Signed on 07/15/2025 12:21 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	MGIL'S CARE HOME LLC		FACILITY NUMBER:	502701113
ADMINISTRATOR/ DIRECTOR:	LAMOCA, MEIREEN I.		FACILITY TYPE:	735
ADDRESS:	2116 STARLIGHT DRIVE		TELEPHONE:	(209) 300-7323
CITY:	MODESTO	STATE: CA	ZIP CODE:	95357
CAPACITY: 4		CENSUS: 3	DATE:	07/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Meireen Lamoca, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 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	At 9:45 AM on 07/15/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection and was greeted by the Co-Administrator. The LPA identified herself, explained the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). The DFA arrived at the facility at 10:15 AM and a brief interview followed. The DFA accompanied the LPA on a tour of the physical plant. The CARE inspection tool was used during this inspection. This facility was licensed to serve 4 non-ambulatory clients. The census was 3 residents; none were home at the time of this visit. The LPA toured the inside of the house, including four resident bedrooms, the kitchen, the two bathrooms, the laundry room, the living/dning room combo, and the garage. The entire house was very clean, odor-free, and pest-free. Each bedroom was single-occupancy; three were currently occupied and one was vacant. Each occupied bedroom had the required furniture and closet space for personal belongings. The windows and window screens were in good repair. One bathroom was a shared bathroom located in the bedroom area hallway and one bathroom was connected to the master bedroom. The bathrooms were clean and the water temperature at the bathroom sink was 109 degrees Fahrenheit. The LPA observed that the temperature in the house was set at 72 degrees Fahrenheit. There were three smoke/carbon monoxide detectors -one in the entry hallway, one in the bedroom hallway, and one in the master bedroom. The DFA tested all three detectors -they are all operable, sounded an alarm, and were an interconnected system. The fire extinguisher was located hanging on the wall in the entry hall. It was last serviced on 2/21/2025 by Assured Fire Extinguisher Services. There was a nightlight in the bedroom hallway.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MGIL'S CARE HOME LLC	FACILITY NUMBER: 502701113
	VISIT DATE: 07/15/2025

NARRATIVE

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The LPA toured the kitchen. The kitchen was clean, the appliances were operable, and the trash can had a lid on it. There was a seven-day non-perishable and two-day perishable supply of food located in the kitchen refrigerator/freezer, kitchen cabinets, and in an extra freezer and cabinets in the garage. Sharp objects were kept under lock and key in a drawer in the kitchen, and kitchen cleaners were locked beneath the kitchen sink.

The LPA toured the dining room and living room, which contained enough furniture for all residents, including a dining table and chairs, two couches, and a recliner. The facility maintained a monthly activity schedule, including shopping, games, movies, and arts and crafts. The LPA observed many live potted plants in the common area.

The LPA toured the laundry room and the garage. Laundry detergent and household cleaners are kept in locked cabinets in the garage. The garage was also used for storage of extra food, household supplies, and extra bedding.

The LPA toured the back yard, which included a shaded area with outdoor furniture, a barbecue, and two sheds with gardening supplies. The backyard included a fruit tree and vegetable garden. The concrete walkways and patio are free of obstruction and the surrounding fence is intact and sturdy.

The DFA conducted fire drills on a quarterly basis. The LPA observed documentation of these drills and signed monthly review and updates of the facility emergency disaster plan.

The LPA inspected the central medication storage area. Residents’ medication was kept in a locked cabinet in the living room. Each resident’s medication was stored separately in its original containers with intact labels. The LPA observed the paper-based medication administration record, which was complete. There was a first aid kit that contained all the required items.

The LPA reviewed records for three residents and two staff. The LPA observed that the records were organized and complete. All staff associated with the facility had criminal background clearances, current first aid/CPR certifications, and proof of annual training. The Administrator’s certificate was valid (#7019976735, expires 7/30/25). The DFA has submitted renewal application paperwork.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MGIL'S CARE HOME LLC	FACILITY NUMBER: 502701113
	VISIT DATE: 07/15/2025

NARRATIVE

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The LPA requested that updated copies of these documents be submitted to Licensing. The DFA submitted items # 1, 2, 3, 4, 5, and 6 at the time of the site visit.

(1) LIC 308 Designation of Facility Responsibility
(2) Copy of a current Administrator Certificate
(3) LIC 610 Emergency Disaster Plan
(4) Proof of Liability Insurance
(5) LIC 500 Personnel Report
(6) LIC 309 Administrative Organization

As a result of this inspection, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6.

An exit interview was conducted with the DFA, to whom a copy of this LIC809 report was provided. Their signature below confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

LIC809 (FAS) - (06/04)

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