342701807-3-19-2026-27-AS-CTAO-DSBP7U-20260319110430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701807
Report Date: 03/19/2026
Date Signed: 03/19/2026 11:04:42 AM

Document Has Been Signed on 03/19/2026 11:04 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:	MGM CARE HOME INC		FACILITY NUMBER:	342701807
ADMINISTRATOR/ DIRECTOR:	SARMIENTO, MICHAEL		FACILITY TYPE:	740
ADDRESS:	9581 BALLINGER DR		TELEPHONE:	(214) 799-9438
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY: 6		CENSUS: 0	DATE:	03/19/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:09 AM
MET WITH:	Michael Sarmiento		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

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	On 03/19/2026, Licensing Program Analyst (LPA) Cynthia Tamayo arrived at the facility, announced, to conduct a pre-licensing inspection to ensure compliance with Title 22 regulations. LPA met with applicant Michael Sarmiento, Gabby Mendoza, and Michelle Tindogan both of whom assisted with the inspection. Applicant Michael Sarmiento, will serve as the administrator of the facility. The administrator certificate number is 6076710740, with an expiration date of 5/7/2027. The facility has a fire clearance for three non ambulatory, 3 bedridden, 6 total. Two bedridden, in bedroom #1, one non ambulatory in bedroom #2, two non ambilatory in bedroom #3, and on edridden in room #4. The applicant is seeking licensure residential care elderly to serve 6 ambulatory adults age range 60 and over to accept and retain adult clients at any given time. The facility will not employ live-in staff; however, staff will work scheduled shifts to provide 24-hour care and supervision. At the time of the inspection, there were no clients in care. LPA Tamayo toured the facility and reviewed the facility sketch. The physical plant was observed to be consistent with the approved fire clearance (STD 850). LPA Tamayo also advised the applicant that the physical plant cannot be altered or changed without first notifying the Department and that the facility must adhere to the original facility sketch submitted to the Department. The kitchen area was toured, and a review of the food supply was conducted to verify compliance. It was observed that the two day perishable food supply and the seven day non-perishable food supply requirement was met. A locked medication cabinet was observed in the kitchen. A first aid kit containing the required components was observed and complete. A fire extinguisher was located in the common area and was last service on 12/16/25 CONTINUED ON 809

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

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: MGM CARE HOME INC	FACILITY NUMBER: 342701807
	VISIT DATE: 03/19/2026

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The common area was toured, and furniture and furnishings were observed to be in good repair. Activities were observed to be accessible to clients in the common area. The backyard was toured, and no hazards were observed. The perimeter gate was in good repair, and the emergency exit was unobstructed. The patio covering was observed to be in good condition. The garage was toured, and no concerns were observed. Detergents, toxins, and cleaning supplies were observed to be locked and inaccessible.

Client bedrooms were toured, and furniture and furnishings were observed to meet client needs. A linen closet located in the hallway contained a sufficient supply of linens at the time of the inspection. Hot water temperature measured 114.6° F, which is within the regulatory range of 105°F to 120°F. The facility thermostat was observed to be set at 71°F , which is within the regulatory range of 68°F to 85°F. Centrally stored medications storage location was observed in a hallway cabinet and were locked. The facility was observed to have a designated, locked area for clients and staff files.

Component III orientation was reviewed with applicants. LPA Tamayo will notify Centralized Applications Bureau (CAB) that the pre-licensing and Component III Orientations has been completed. An exit interview was conducted with applicants, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC809 (FAS) - (06/04)

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