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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701141
Report Date: 04/08/2022
Date Signed: 04/19/2022 02:26:16 PM

Document Has Been Signed on 04/19/2022 02:26 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:MIRACLE CARE HOMEFACILITY NUMBER:
502701141
ADMINISTRATOR:CASILLAS, MARICELFACILITY TYPE:
735
ADDRESS:1112 MUIRSWOOD WAYTELEPHONE:
(209) 688-1181
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 0DATE:
04/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maricel CasillasTIME COMPLETED:
12:00 PM
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Announced Prelicensing visit made out to this facility by Licensing Program Analyst (LPA) Charlie Yang on 04/08/2022. This LPA was met by the Applicant, Maricel Casillas, who was briefly interviewed prior to the facility walk through.
This Applicant is seeking licensure for a 4-bed Adult Residential Facility to accept and retain (3) ambulatory only residents and (1) nonambulatory resident at this time. It was also learned that this Applicant is in the process of vendorization through Valley Mountain Regional Center for a level 4I care home.
Current census was 0 residents.
Tour of the this facility was conducted.
A tour of the living room, dining room, and all other interior areas intended for use by the residents was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the kitchen was conducted. Food storage for 2-day perishable supply was observed to be sufficient and able to meet the needs of the residents at this time. A review of the nonperishable food supply was observed to be sufficient and able to meet the needs of the residents at this time.
Cabinets and drawers were opened and reviewed for adequate plates, utensils, and cook ware at this time.
Fire extinguisher, located in the kitchen area, was reviewed for annual purchase date or inspection date. It was observed that it was recently purchased on 02/21/2022 and in compliance at this time.
A tour of the facility resident rooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken in the resident restrooms to make sure that they were within the allowed range of 105-120 degrees.
A review of the medication cabinet was conducted. First aid kit was observed to be present and contained all of the required components at this time.
A review of the storage cabinet housing cleaning agents and supplies was observed to be locked and made inaccessible to the residents at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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: MIRACLE CARE HOME
FACILITY NUMBER: 502701141
VISIT DATE: 04/08/2022
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A tour of laundry area was conducted in the garage area. Laundry detergents and bleach were observed to be locked and made inaccessible at this time.
A tour of the facility exterior grounds was conducted. It was observed that there were ramps in place and in compliance at this time.
A review of the facility perimeter fence, side fence, and emergency exits was conducted.
Component III was reviewed with facility Applicant at this time.

This facility was found to be in compliance at this time.


Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
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