<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202689
Report Date: 03/21/2025
Date Signed: 04/10/2025 08:30:17 AM

Document Has Been Signed on 04/10/2025 08:30 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SONGBIRD IN THE COUNTRYFACILITY NUMBER:
275202689
ADMINISTRATOR/
DIRECTOR:		MAZERIK, BETHFACILITY TYPE:
740
ADDRESS:15961 TORO HILLS AVENUETELEPHONE:
(831) 998-8708
CITY:SALINASSTATE: CAZIP CODE:
93908
CAPACITY: 12CENSUS: 8DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Licensee, Mathew MazerikTIME VISIT/
INSPECTION COMPLETED:
03:15 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) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee Mathew Mazerick Continual Administrator's Certification expires 11/13/2025. There are currently 8 residents who reside at this home and there is 3 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

Water temperature was tested at 141 degrees. Staff 1, and staff 2 does not have current CPR/First aid training. Licensing was not notified of Resident 1's admission to hospice. The facility does not have a Plan of Operation available for review. Several facility staff did not have required Health screening form.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee, Mathew Mazerick and copy of report left at facility
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Sarah Hurt
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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 04/10/2025 08:30 AM - It Cannot Be Edited


Created By: Sarah Hurt On 03/21/2025 at 02:07 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
,
, CA

FACILITY NAME: SONGBIRD IN THE COUNTRY
FACILITY NUMBER: 275202689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal right the facility water temperature in two resident bedroom sinks is measuring above 120 degrees, risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
1
2
3
4
Licensee will ensure the facility resident bathroom water temperatures measuring between 105 and 120 and send proof to LPA by POC date 04/04/2025.
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General


(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Staff 1, and staff 2 do not have required first aid/CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
1
2
3
4
Licensee will send proof of required First aid training to LPA by 04/04/2025 POC date.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2