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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005680
Report Date: 03/20/2026
Date Signed: 03/20/2026 03:16:54 PM

Document Has Been Signed on 03/20/2026 03:16 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:
03/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:33 PM
MET WITH:Facility Staff: Balbino GarciaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 03/20/2026 at 12:30 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with caregiver Balbino and explained the purpose of the visit, LPA called the facility designated administrator to inform that CCLD was present in the facility, however their voicemail was full. The current census is 2 with 1 facility staff present.

This facility is a single story building licensed to serve (6) non-ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 117.7 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety.  The fire extinguisher is located in the entry way and was last serviced on 03/09/2026. LPA observed the facility has a public telephone in the staff room and the facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit. LPA observed toxins located in the kitchen cabinet kept locked and inaccessible to residents. LPA observed sharp knives kept locked in the kitchen and inaccessible to residents.

Continuation 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Shakaricka Hughes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2026
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 6
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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Document Has Been Signed on 03/20/2026 03:16 PM - It Cannot Be Edited


Created By: Shakaricka Hughes On 03/20/2026 at 02:30 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IMMACULATE CARE HOME
FACILITY NUMBER: 347005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on facility observation the licensee did not comply with the section cited above in 3 out of 3 counts which poses an immediate health and safety risk to persons in care. During staff records review, LPA observed staff records for 3 out of 3 facility staff with outdated first aid training.
POC Due Date: 03/27/2026
Plan of Correction
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Licensee agrees to replace missing CPR training certification records for 3 facility staff or provide training resource for re-training of CPR certification for facility staff by 3/27/2026 Licensee agrees to provide proof of CPR certification to LPA via email at shakaricka.hughes@dss.ca.gov by 3/27/2026.
Type A
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 observation the licensee did not comply with the section cited above which poses an immediate safefty risk to persons in care. Based on records review the facility did not ensure emergency drills were conducted in the facility quarterly. LPA observed the last emergency drill on record 03/27/2025.
POC Due Date: 03/27/2026
Plan of Correction
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The licensee agrees to conduct quarterly training, and maintain records/logs of emergency drill conducted in the facility. Licensee agrees to provide LPA Hughes a recent copy of a fire drill log used in the facility by 3/27/2026 via email at shakaricka.hughes@dss.ca.gov by 3/27/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Shakaricka Hughes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/20/2026 03:16 PM - It Cannot Be Edited


Created By: Shakaricka Hughes On 03/20/2026 at 02:30 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IMMACULATE CARE HOME
FACILITY NUMBER: 347005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in which poses a potential health and safety risk to persons in care. Based on review of staff records, LPA observed 2 out of 3 staff records (S1) and (S3)without Health screening records, including TB testing results.
POC Due Date: 03/27/2026
Plan of Correction
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Licensee agrees to provide LPA with proof of Health Screening LIC 503 records, and TB testing results for facility (S1) and (S3) by 3/27/2026 via email at shakaricka.hughes@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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Shakaricka Hughes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2026 03:16 PM - It Cannot Be Edited


Created By: Shakaricka Hughes On 03/20/2026 at 02:30 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: IMMACULATE CARE HOME
FACILITY NUMBER: 347005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2026

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 and facility staff (S2) which poses a potential health, safety or personal rights risk to persons in care. Based on observation of staff records, LPA observed an incomplete record for the 2 out of 3 facility staff. LIC 501, LIC 503, LIC 508, Expired First Aid certification.
POC Due Date: 03/27/2026
Plan of Correction
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Licensee agrees to provide LPA with a scan of Maryimmaculate Muiruri's and Margaret Kamau complete personnel file by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Shakaricka Hughes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 03/20/2026
NARRATIVE
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LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 2 out of 2 residents medications and the Centrally Stored Medication Destruction Record (CSMDR) was complete. The first aid kit was checked and contained the required components.


LPA requested resident and staff files for review. LPA reviewed 2 out of 2 resident files and they were complete. LPA requested 3 out of 3 staff files for review, and observed the files incomplete, as facility staff were missing records. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared.

The following documents will be email to LPA by 03/24/2026

(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate   
(3) LIC 610 Current Emergency Disaster Plan
(4) Proof of Current Liability Insurance
(5) LIC 500 Current Personnel Report


As a result of this annual visit, the facility is not in compliance with Title 22 Regulations, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility. A copy of this report will be emailed to the licensee.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Shakaricka Hughes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026
LIC809 (FAS) - (06/04)
Page: 6 of 6