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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005680
Report Date: 03/13/2025
Date Signed: 03/13/2025 12:24:32 PM

Document Has Been Signed on 03/13/2025 12:24 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:IMMACULATE CARE HOMEFACILITY NUMBER:
347005680
ADMINISTRATOR/
DIRECTOR:		MUIRURI, MARYIMMACULATEFACILITY TYPE:
740
ADDRESS:8892 MONTEREY OAKS DRIVETELEPHONE:
(916) 236-7339
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 2DATE:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Balbino GarciaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski and Administrative Assistant Nicholas Morisi arrived unannounced to conduct an annual inspection. LPA Moleski met with staff member Balbino Garcia and explained the purpose of the visit.

LPA Moleski reviewed Garcia's staff file. LPA Moleski asked for files for both of the clients currently in care, and for a staff file for Maryimmaculate Muiruri, the licensee. Garcia said that, as far as he was aware, files were not made for either client, both of whom moved in about six months ago. Garcia could not locate Muiruri's file. LPA Moleski called Muiruri and left a voicemail for her. Garcia said that Muiruri had not been working at this facility much recently. LPA Moleski asked to see records of emergency disaster drills. Garcia said they had not been conducted.

Garcia said one resident, R2, had a stage two wound on their heel. LPA Moleski asked to see R2's home health care plan, or visit notes from home health nurses. Garcia did not have either of these available. While speaking with R2, R2 said that they had diabetes, and that Garcia performed blood glucose testing for R2. Garcia admitted that he had occasionally performed blood glucose testing for R2.

LPA Moleski asked to see centrally stored medication records for R1-R2. Garcia provided a centrally stored medication record for R1 from July 2024, when R1 moved in. Garcia said no additional centrally stored medication records were available. LPA Moleski observed that R2's medication, which was stored in a locked storage area, was kept in a seven-day dispenser, rather than in its originally received container. LPA Moleski toured the facility with Garcia and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 69 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. [continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 03/13/2025 12:24 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/13/2025 at 11:24 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IMMACULATE CARE HOME
FACILITY NUMBER: 347005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87631(a)(3)(B)
"All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, no documentation from home health care professionals regarding R2's wound were kept on the premises, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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2
3
4
Licensee agrees to provide LPA Moleski with a copy of R2's home health care plan by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


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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: IMMACULATE CARE HOME
FACILITY NUMBER: 347005680
VISIT DATE: 03/13/2025
NARRATIVE
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LPA Moleski observed first aid supplies and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski observed a fire extinguisher which had not been serviced within the last year, as required.

LPA Moleski interviewed one staff member (S1) and two residents (R1-R2).

This facility is hereby cited per 22 CCR Sections 87202(a), 87465(h)(5), 87412(a), 87465(a)(6), 87506(a), 87631(a)(3)(B), and 87628(a), and Health and Safety Code Section 1569.695(c). An exit interview was held with Garcia. Appeal rights and a copy of this report were left with Garcia.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
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Page: 3 of 7
Document Has Been Signed on 03/13/2025 12:24 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/13/2025 at 11:35 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IMMACULATE CARE HOME
FACILITY NUMBER: 347005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, a fire extinguisher was not annually serviced, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee agrees to either schedule maintenance services for the facility fire extinguisher or to purchase a new fire extinguisher by POC due date. Licensee further agrees to provide LPA Moleski with proof of having scheduled said services or a photograph of a receipt for a new fire extinguisher.
vincent.moleski@dss.ca.gov
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, medication was stored in a seven-day tablet dispenser, rather than in originally received packaging, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee agrees to stop using the seven-day tablet dispenser and to send LPA Moleski a signed statement acknowledging that medications must be stored only in their originally received packages by POC due date.
vincent.moleski@dss.ca.gov
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


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Page: 4 of 7
Document Has Been Signed on 03/13/2025 12:24 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/13/2025 at 11:35 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IMMACULATE CARE HOME
FACILITY NUMBER: 347005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, a personnel record was not maintained on the licensee, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with a scan of Maryimmaculate Muiruri's complete personnel file by POC due date. Licensee also agrees to provide LPA Moleski with Muiruri's work schedule for this facility for the next three months.
vincent.moleski@dss.ca.gov
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, centrally stored medication records were not kept up to date or complete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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3
4
Licensee agrees to provide LPA Moleski with centrally stored medication records for current dosages on hand for both residents by POC due date.
vincent.moleski@dss.ca.gov
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/13/2025 12:24 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/13/2025 at 11:35 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IMMACULATE CARE HOME
FACILITY NUMBER: 347005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, both residents of this facility did not have resident records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with complete scans for both residents' records by POC due date.
vincent.moleski@dss.ca.gov
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, fire drills were not conducted or documented, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with a schedule of planned emergency disaster drills for the rest of the year by POC due date. This schedule should also outline the topics to be covered in the drill, and the persons who will be present.
vincent.moleski@dss.ca.gov
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


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Document Has Been Signed on 03/13/2025 12:24 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/13/2025 at 11:51 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IMMACULATE CARE HOME
FACILITY NUMBER: 347005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87628(a)
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, a staff member performed blood glucose testing for a resident who was not able, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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2
3
4
Licensee agrees to provide a written statement acknowledging that all residents must perform their own blood glucose testing, if a nurse is not available to do so, by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


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