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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005502
Report Date: 09/20/2021
Date Signed: 09/20/2021 10:08:44 AM

Document Has Been Signed on 09/20/2021 10:08 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MARYANN PATACSIL'S CARE HOME #1FACILITY NUMBER:
397005502
ADMINISTRATOR:MARYANN PATACSILFACILITY TYPE:
735
ADDRESS:329 PRADO WAYTELEPHONE:
(209) 477-5219
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 6DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Marilyn PatacsilTIME COMPLETED:
10:15 AM
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On 9/20/2021 Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual Inspection at 8:30am and met with Designated Staff One (S1). LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 clients and today's census is 6. S1 and Staff two (S2) who arrived shortly after LPA accompanied LPA on facility tour. Designated Staff three (S3) arrived there after. Three of three staff observed on site with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 11/29/2022. Prior to today's visit LPA contacted Licensee for COVID screening who confirmed no staff or clients have shown symptoms or tested positive in the past ten days.

LPA interacted with a random number of clients during this visit and observed clients. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed kitchen, garage, restroom, bedrooms, and common living areas to be clean and in good repair. LPA observed items stored not in use including gutter downspout, roof repair items, and loose bricks. LPA observed toxins, knives, centrally store medications stored inaccessible to clients. The temperature inside the facility was measured at 71*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 115*F within regulatory range of is not less than 105*F and not more than 120*F.

The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution.

Facility handles P & I monies, LPA observed the log is maintained correctly and there is no commingling of funds. LPA observed the facility conducts fire drills documented monthly.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MARYANN PATACSIL'S CARE HOME #1
FACILITY NUMBER: 397005502
VISIT DATE: 09/20/2021
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LPA observed fire extinguisher last inspected on 3/12/2021, pull alarm system, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed one carbon monoxide dector removed, S1 stated she took it down last night due to beeping and was in process of purchasing a new one today as thebatteries were not working and will be completed before lunch time. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap, touchless covered trash cans, and posted hand washing signs, one sign not posted in resident restroom as resident one (R1) keeps taking it down. 30 day supply of PPE stored off site with supplies available on site for staff.

Upon a file review the following items were discussed to be submitted with any changes to LPA by 10/8/2021:

Administrative Organization LIC309
Control of Property
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Affidavit Regarding Client/Resident Cash Resources LIC400
Surety Bond LIC402
Emergency Disaster Plan LIC610D
First aid/CPR certificates

Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC809 (FAS) - (06/04)
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