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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701141
Report Date: 04/26/2024
Date Signed: 04/26/2024 03:08:22 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/26/2024 03:08 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:MIRACLE CARE HOMEFACILITY NUMBER:
502701141
ADMINISTRATOR/
DIRECTOR:		CASILLAS, MARICELFACILITY TYPE:
735
ADDRESS:1112 MUIRSWOOD WAYTELEPHONE:
(209) 688-1181
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 0DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Maricel CasillaTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 04/26/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Maricel Casillas.

This facility is licensed seeking to accept and retain up to 4 residents, of which 3 may be ambulatory with 1 resident who can be non-ambulatory at any given time. This facility is awaiting vendorization to accept and retain Level 4I residents at this time.
The facility designated Administrator, Maricel Casillas, did have her Administrator certificate posted with an expiration date of #7018782735 and expires at 07/16/2025 and in compliance at this time.
A review of the facility personnel file for the facility designated Administrator was conducted.

Tour of the facility was conducted.

Common areas were toured. Dining area, living area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Kitchen area was toured. Cabinets and drawers were reviewed.
Fire extinguisher, hanging on kitchen wall, was observed to have been annually purchased from the local home improvement store with receipt attached at this time.
Cabinet below the sink was reviewed. It was observed to contain cleaning agents and supplies which were locked and made inaccessible at this time.
A tour of the facility resident bedrooms was conducted. Furnishings and furniture were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility resident restrooms was conducted. Grab bars and nonskid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at this time.
Food storage supply was reviewed. This LPA observed 2-day perishable food supplies and 7-day nonperishable food supplies at this time.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MIRACLE CARE HOME
FACILITY NUMBER: 502701141
VISIT DATE: 04/26/2024
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Garage area was toured. Laundry machines, washer and dryer, were observed to be present and in good repair at this time. Bleach, detergent, and additional cleaners were observed to be present at this time but the door leading to this garage was equipped with a locking mechanism to prevent access at this time.
Linen closet, located in hallway, was observed to be supplied with blankets, sheets, and additional linens to meet the needs of the residents at this time.

A tour of the exterior grounds was conducted.
The facility perimeter fence, side gate, and exits were reviewed.
The following forms and documents were requested by this LPA to be updated and submitted into CCL for review by this LPA:
-LIC 308
-LIC 400
-LIC 500
-LIC 610

There were no deficiencies observed or cited during today's annual visit.



An exit interview was conducted and a copy of this report was provided at the end of the visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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