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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005500
Report Date: 05/07/2026
Date Signed: 05/08/2026 09:04:25 AM

Document Has Been Signed on 05/08/2026 09:04 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HUMMINGBIRD COURT CARE HOMEFACILITY NUMBER:
507005500
ADMINISTRATOR/
DIRECTOR:		ESCORIDO, ROSELYNFACILITY TYPE:
735
ADDRESS:3124 HUMMINGBIRD CTTELEPHONE:
(209) 577-5830
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 5DATE:
05/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Merlita Sacatropez and Alicia OmoregbeeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 05/07/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility live-in caregivers, Merlita Sacatropez and Alicia Omoregbee, at this time. A brief interview was conducted with the facility live-in caregivers at this time. This LPA requested that they go ahead and contact the facility designated Administrator, Macherry Macasarte, to inform her that CCL was present at this time. The facility designated Administrator was unable to be present for this annual visit with this LPA.
It was learned that this facility was vendorized to be able to accept and retain up to (6) Level 6 residents at any given time. This facility was licensed to serve up to (6) Non Ambulatory residents at any given time. Current census was 5 residents, of which (2) of them, were out of the facility at their respectable day programs at this time.
Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies which were stored in a closet and were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the facility kitchen overhead cabinet, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility live-in caregivers at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2026
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: HUMMINGBIRD COURT CARE HOME
FACILITY NUMBER: 507005500
VISIT DATE: 05/07/2026
NARRATIVE
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Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.
Administrator Certificate for Macherry Macasarte was observed to have a renewal date of 02/12/2027 with the following certificate #6075781735 at this time.
A tour of the resident bedrooms 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 resident restrooms was conducted. Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area located in the garage area was toured. Cleaning supplies, detergents, and bleach were observed to be locked and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to be placed in the living area of this facility and was recently reviewed by the local fire extinguisher company, Touch Down Fire Inc., on 03/16/2026 and in compliance at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (5) facility resident files was conducted and noted on the following LIC 858.
A review of (4) facility staff files was conducted and noted on the following LIC 859.
The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:
LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and noted on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was left with the facility live in caregivers at this time. Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/08/2026 09:04 AM - It Cannot Be Edited


Created By: Charlie Yang On 05/07/2026 at 01:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HUMMINGBIRD COURT CARE HOME
FACILITY NUMBER: 507005500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the tiles in the facility restroom and shower area were cracked and in need of repair. In addition, the exterior side gate could not be opened fully to allow residents to exit in case of emergency which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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The facility representative stated that the restroom tiles and side exit will be repaired/replaced as necessary to function properly and not pose a risk to the residents in care. A statement of correction, along with proof of repaired/replaced tiles and side gate, will be completed and submitted into CCL by the due date for review by this LPA.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the hot water measured in the resident restroom was found to be at 124.7 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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The facility representative stated that the hot water heater will be turned down to make sure that hot water temperatures are within the allowed range of 105-120 degrees at all times. A statement of correction, along with proof of daily temperatures being taken for (3) days, will be completed and submitted into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/08/2026 09:04 AM - It Cannot Be Edited


Created By: Charlie Yang On 05/07/2026 at 01:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HUMMINGBIRD COURT CARE HOME
FACILITY NUMBER: 507005500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [2] out of [5] facility resident files did not possess a proper completed medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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The facility representative stated that the resident files will be audited to make sure that they are complete and updated at all times containing the medical assessment A statement of correction, along with proof of complete and updated medical assessment, will be completed and submitted into CCL by the due date for review by this LPA.
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the Medication Administration Record (MAR), along with the dispensing log, were not properly updated and documented when the medications were being dispensed to the residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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The facility representative stated that the resident Medication Administration Records will be audited to make sure that they are complete and properly updated with personnel initials at all times when the medications are dispensed to the residents in care. A statement of correction, along with proof of training for no less than (1) hr in duration, will be completed on the topics of proper dispensing, handling, and documentation with submission into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/08/2026 09:04 AM - It Cannot Be Edited


Created By: Charlie Yang On 05/07/2026 at 01:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HUMMINGBIRD COURT CARE HOME
FACILITY NUMBER: 507005500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there were window screens and sliding window door screens in need of repair/replacement since they had holes, tears, or were off track which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2026
Plan of Correction
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The facility representative stated that the window screens and sliding door screens will be repaired/replaced as necessary to function properly and not pose a risk to the residents in care. A statement of correction, along with proof of repaired/replaced window screens, will be completed and submitted into CCL by the due date for review by this LPA.
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [2] out of [5] facility residents did not have a file complete with required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2026
Plan of Correction
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The facility representative stated that the resident files will be audited to make sure that they are complete and contain all required forms and documents at all times. A statement of correction, along with proof of updated resident files, will be completed and submitted into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2026


LIC809 (FAS) - (06/04)
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