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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701139
Report Date: 03/17/2023
Date Signed: 03/21/2023 08:10:37 AM

Document Has Been Signed on 03/21/2023 08:10 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:MY HOME SWEET CARE LLCFACILITY NUMBER:
502701139
ADMINISTRATOR:XIONG, MAIFACILITY TYPE:
735
ADDRESS:2709 MARINA DRTELEPHONE:
(209) 401-3454
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 3DATE:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mai Xiong TIME COMPLETED:
11:00 AM
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On 03/17/2023 at 9:30 am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an Annual visit. LPA Pascua was greeted by Facility Designated Administrator, Mai Xiong and explained the purpose of the visit. The current census was 3. 2 out of 3 residents were out at their respective day program at this time. This facility is licensed to serve up to 4 residents who deemed ambulatory only. This facility is also vendorized by Valley Regional Center to hold and accept Level 4I residents at this time. A brief interview with FDA Xiong was conducted.

LPA Pascua reviewed 3 resident files. 3 out of 3 resident files were current and up to date. LPA Pascua reviewed 8 staff files. 8 out of 8 staff files were current and up to date. Facility Designated Administrator currently has an active certification #6050083735 and expires on 10/29/2024.
A tour of the facility was conducted. Fire extinguisher located in the kitchen and was serviced by USA Stanislaus Fire on 01/06/2023.
LPA observed a locked centralized stored medication cabinet located in the hallway. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care.
A tour of the garage was conducted. Additional storage for supplies were identified. Additional food supply was identified.
A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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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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: MY HOME SWEET CARE LLC
FACILITY NUMBER: 502701139
VISIT DATE: 03/17/2023
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A tour of the 4 resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time.

A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.

The exterior of the physical plant was in good repair with no hazards present. 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

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.
Exit interview was conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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