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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002671
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:40:59 PM

Document Has Been Signed on 04/14/2022 04:40 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:M & L CARE HOMEFACILITY NUMBER:
585002671
ADMINISTRATOR:AGUIRRE, LEAHFACILITY TYPE:
735
ADDRESS:5656 MEADOW BROOKWAYTELEPHONE:
(858) 371-8830
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ayson Aguirre, StaffTIME COMPLETED:
04:45 PM
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On 4/14/2022 around 3:00pm, Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with facility staff Ayson Aguirre and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA and Staff toured the facility inside and out to ensure health and safety of clients in care. During today's inspection, there are 4 clients and 2 staff member present.. Areas toured include but are not limited to: common area, 4 client private bedroom, 1 shared bathroom, 1 staff room, 1 staff bathroom, 1 game activity room, laundry room, and garage. LPA and staff completed the infection control domain during today's inspection. Around 3:07pm, LPA and Staff observed some over-the-counter medications and ointments on the top of the dresser by the door and Television stand in the staff room. Staff immediately removed all over-the-counter medications and ointment during the inspection.

During today's inspection, LPA and staff reviewed 4 out of 4 client P&I Cash and 4 out of 4 client Centrally Stored Medications. LPA reviewed 3 out of 3 staff files and all 3 staff has training and current First Aid/CPR on file.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/14/2022 04:40 PM - It Cannot Be Edited


Created By: Mai Thao On 04/14/2022 at 04:18 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: M & L CARE HOME
FACILITY NUMBER: 585002671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 1 out of 1 staff room, there were accessible medications and ointments to clients in the unlocked staff room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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During the inspection staff immediately removed all medications and ointments and locked it. Licensee agrees to submit in a plan to Licensing stating how Licensee can ensure medications are inaccessible to clients in care by 4/15/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Ordonez
LICENSING EVALUATOR NAME:Mai Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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