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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701405
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:14:38 PM


Document Has Been Signed on 07/16/2024 04:14 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:MOTHER'S HOUSE BY WESTSIDEFACILITY NUMBER:
502701405
ADMINISTRATOR:BROOKS, PATTY LYNNFACILITY TYPE:
740
ADDRESS:1032 SOUZA COURTTELEPHONE:
(209) 641-8679
CITY:NEWMANSTATE: CAZIP CODE:
95360
CAPACITY:6CENSUS: 0DATE:
07/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Patty Lynn Brooks, AdministratorTIME COMPLETED:
04:30 PM
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On 07/16/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility announced to conduct a pre-licensing inspection. LPA Campbell met with Administrator Patty Lynn Brooks and William Brooks, Facility Manager and explained the purpose of the visit. Upon entry, LPA Campbell observed the sign in sheet and the common/living room area for residents. The facility is a one story building with 6 bedrooms and 3 bathrooms. The walls and floors were clean and in good repair and were free from hazards or obstructions. Smoke alarms were connected to the carbon monoxide alarm and were found to be functioning. Fire extinguishers were fully charged. Cleaning solutions and other hazardous items were stored in the locked laundry room. Door alarms were observed on all exterior entrances and no body of water was found.

Bedroom 5 will be shared between two clients and have its own bathroom (a). Bedroom 4 and 3 will be for single bedridden clients. Bedroom 6 is a staff room with an en suite bathroom (b), bed and office. Bedroom 1 and 2 will be for single clients and will have one bathroom (c) to share between them. At this time, bathroom (c) has a curtain Instead of a door. All bathrooms had non slip non-skid mats. All bedrooms contained mattresses, box springs, linens, a closet, night stand, lamp, a chair and a chest of drawers for each occupant. The hot water is measured at 116 degrees Fahrenheit which is within the required temperature of105 to 120 degrees Fahrenheit.

Medications were locked in a closet along with a safe for narcotics. See Something Say Something information was displayed for residents next to the locked medication closet. The first aid kit was observed as complete with scissors, tweezers and thermometer as well as bandages and antiseptic wipes. Forms for residents and staff as well as Medication Administration Record forms are available and ready for use. LPA Campbell observed the Emergency and Disaster Plan in a binder as well as at the entrance of the facility.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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: MOTHER'S HOUSE BY WESTSIDE
FACILITY NUMBER: 502701405
VISIT DATE: 07/16/2024
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Sharps were observed to be locked in the kitchen. Refrigerator 1 in the kitchen was measured at 0 degrees Fahrenheit for the freezer and the refrigerator was set at 37 degrees Fahrenheit. Refrigerator 2 was observed in the garage and the freezer and refrigerator temperatures were within regulation. Emergency food supplies were stored on top of freezer number 3 in the garage as well. A 2015 Ford Fusion was parked outside of the facility and will be used as transportation for the residents

Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to not be in compliance at this time.

The following item will need to be completed before moving forward with the application process:

-- The fire department completed a second inspection that added an addendum regarding the locked gates. Per Administrator Patty Brooks, because the backyard has more than 50 feet for a safety evacuation perimeter, the facility can lock the side gates. LPA Campbell has called the Fire Inspector and requested a copy of the second inspection with details noted on the Fire Safety Inspection Request (STD 850). Once the updated report is received, the facility will be cleared to lock the side gate entrance.

-The facility will have to add a door to bathroom (c) to ensure privacy for residents.

LPA Campbell will return to the facility when the corrections have been made. Applicant was informed to call LPA Campbell when the correction has been completed.

An exit interview was conducted, and a copy of this report was given to the applicant.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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