502701405-8-5-2026-27-AS-NWPN-DWNU63-20260805151739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701405
Report Date: 08/05/2026
Date Signed: 08/05/2026 03:17:47 PM

Document Has Been Signed on 08/05/2026 03:17 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 WESTSIDE		FACILITY NUMBER:	502701405
ADMINISTRATOR/ DIRECTOR:	BROOKS, PATTY LYNN		FACILITY TYPE:	740
ADDRESS:	1032 SOUZA COURT		TELEPHONE:	(209) 641-8679
CITY:	NEWMAN	STATE: CA	ZIP CODE:	95360
CAPACITY: 6		CENSUS: 3	DATE:	08/05/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Patty Brooks		TIME VISIT/ INSPECTION COMPLETED:	03:30 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	Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct the annual inspection. LPA met with administrator Patty Brooks to explain the purpose of the visit. Physical Plant was inspected including the kitchen, bedrooms, bathrooms, common areas, exterior, and evacuation route gate. Facility is clean, the traffic areas are well lit and unobstructed. Kitchen has adequate lockable storage for sharps, toxics, and medication. There is 2 days of storage for perishable food and 7 days of nonperishable food. LPA pointed out 2 cans of expired food, LPA gave guidance to do an 6 month inventory of the food, wipe the containers for dust and remove out of date or damaged items. The bathrooms have functional hardware, water temp is measured at the basin at 110*f. Bedrooms have beds equipped with half rails, LPA gave guidance that all ralls should come with a doctors order. 1 resident has a bedrail order, other 2 residents may or may not have pending bedrails orders. Bedrooms have all required furniture and furnishings. In the common areas, Bedrooms doors have a mounted privacy screen that fits over the door, the kitchen has winding belts that can cordon off the pantry and refrigerator. It's possible that these could be used to prevent access to a common area of the facility, currently the residents seem cognitavely and physically able to bypass the cordon and the privacy screen. The LPA gave guidance to ensure that residents do have access to the common areas of the facility, as the clients decline it may be too restrictive in a personal rights sense and potentially a fire hazard. Exterior has space for activities, evacuation route gate is locked. The LPA reviewed a previous LPA's report on 7/31/24: "The City of Newman Fire Department provided an updated Fire Safety Clearance that clarified the exception to the "Access to a public way" rule found in business code regulations for Building Egress (BE), BE 1028.5." LPA notes house is a relatively modern construction and has sprinklers. Continued on C page

Liza King
Noel Wolf Petersen
	DATE: 08/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026

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: MOTHER'S HOUSE BY WESTSIDE	FACILITY NUMBER: 502701405
	VISIT DATE: 08/05/2026

NARRATIVE

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LPA reviewed 4 of 4 staff files, for the health screening, first aid certification, background clearance, and current/annual training requirements. files are present and up to date.

LPA reviewed 3 of 3 client files, for the signed admission agreement, health screening, needs and services plans, recent health assessments, and if applicable hospice services plans. all clients have an error on the admission agreement informing the client/representative the facility is NOT secured, when it is in fact secured. LPA gave guidance to correct the error, and inform the current clients/representives of the change, re aquire signed admission agreements. 1 client needs an updated needs and services plan following a change in thier needs and services. 1 client needs an updated 602's, dementia clients are updated at least annually. hospice care plan designates a wound care task to the caregivers of the facility, LPA gave guidance to review hospice care plans, if there are tasks for the caregivers they should be continually logged. Facility provided scheduled visit for Aug 19th 2026, to update 602, hospice nurse talked about the bedrails for 1 client while the were here during the visit supported with doc order. Health screening files present and up to date. 2 residents medication and MARs were checked at random, LPA gave guidance that the PRN distribution's need to be filled out every time.

LPA reviewed administrator files, for the infection control plan, evacuation plan, required posters (ombudsman, client rights, right to resident councils, evacuation plan), the facility license, the facility sketch, workers comp/liability insurance. files are present and up to date.

Interviewed 2 staff and 3 clients.

No citations issued. A copy of the report was read and given to the administrator. exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026

LIC809 (FAS) - (06/04)

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