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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701028
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:46:17 PM

Document Has Been Signed on 04/13/2022 03:46 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:MKS QUALITY CARE LLCFACILITY NUMBER:
342701028
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:317 NATOMA ST.TELEPHONE:
(916) 831-7972
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 15CENSUS: 8DATE:
04/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Tatleen LewisTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Lavinia Muscan arrived at the facility unannounced and prior to visit LPAs conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPAs were screened at the front door by Caregiver.

When LPAs arrived at the facility and requested a document from the caregiver who greeted LPAs at the door, LPAs observed that caregiver telling the other two caregivers on duty Licensing arrived and pointed at her face while walking to a cabinet to get the requested document. LPAs observed two caregivers not wearing masks as required by the CA Dept. of Social Services Community Care Licensing Division due to the current pandemic. One caregiver (S1) was eating and the second caregiver(S2) was sitting in a recliner facing the front and walked over to the cabinet that stores the personal protection equipment (PPE) and put a surgical mask on. All caregivers were in the presence of the residents during this time.

The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. Appeal rights left with facility representative.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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Document Has Been Signed on 04/13/2022 03:46 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 04/13/2022 at 02:06 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: MKS QUALITY CARE LLC
FACILITY NUMBER: 342701028

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2022
Section Cited
CCR
87468.1(a)(2)

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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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By 04/14/2022, all staff and management shall have training on current mandates regarding the current pandemic and the licensee shall also submit in writing how he shall ensure all staff follow the mandates.
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LPAs walked in and observed a caregiver sitting in a recliner while with residents and not wearing a mask. LPAs observed a second caregiver telling the first one that Licensing was present and to put a mask on. This is an immediate risk to residents.
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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:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
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