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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004961
Report Date: 10/31/2025
Date Signed: 10/31/2025 12:31:10 PM

Document Has Been Signed on 10/31/2025 12:31 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MARYLOU'S HOME CAREFACILITY NUMBER:
347004961
ADMINISTRATOR/
DIRECTOR:		APUYA, ROMEOFACILITY TYPE:
740
ADDRESS:4194 ENGLE ROADTELEPHONE:
(916) 482-4143
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 5DATE:
10/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:12 AM
MET WITH:Maureen GrantTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct an annual inspection. LPA met with facility administrator care staff, Maureen Graant S1 and explained the purpose of the visit. S1 called the facility administrator and stated they were unable to come to the facility and S1 can assist with the annual inspection. An entrance interview was conducted with S1.

The facility is licensed for a total of six (6) non-ambulatory residents ages 60 and over; Hospice waiver for two (2) granted. The current census is five residents, one staff. LPA observed one staff in the dining room singing along to YouTube videos on their tablet, two resident watching television in the living room and all other residents int their rooms.

LPA observed residents were each given a Halloween treat bag by care staff.
LPA and S1 inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of five residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 119 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA observed a locked cabinet for the storage of medication. LPA observed locked cabinets for the storage of cleaning solutions and knives. The shelf liners in cabinets are warped and in need of repair or replacement.
Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2025
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: MARYLOU'S HOME CARE
FACILITY NUMBER: 347004961
VISIT DATE: 10/31/2025
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LPA requested resident and staff files for review. LPA reviewed three (3) staff files and five (5) resident files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The current administrator, Romeo Apuya is not listed as having a current administrator certificate not only listed on the on current LIC 500 schedule as on-call, an updated administrator certificate or administrator shall be provided by Licensee. Administrator should be at the facility a sufficient number of hours to properly manage the facility. There is a current administrator certificate for Geronima (Emma) Bautista. Two out of five residents are in need of an updated annual physicians visit in November 2025 and are scheduled already. Licensee shall have enough staff to ensure care for five residents including meeting care needs and providing activities for residents.

The following forms were requested to be submitted by 11/07/2025 to Cynthia.tamayo@dss.ca.gov:
• LIC 500 Personnel Record
LIC 308 Designation of Administrative Responsibility
• LIC 309 Designation of Administrative Responsibility
• Updated LIC 500 Personnel Report
• LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance
• LIC 9020 Register of facility clients/residents
• Copy of Administrator Certificate(s)
• Update Administrator with CCLD, if Romeo Apuya is no longer the administrator

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 no deficiencies were cited during this visit. Technical assistance was provided as described above. An exit interview was conducted and a copy of this report was left with staff member Maureen Grant.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC809 (FAS) - (06/04)
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