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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 11/09/2022
Date Signed: 11/09/2022 03:20:19 PM

Document Has Been Signed on 11/09/2022 03:20 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MOTHER MARY CARE HOMEFACILITY NUMBER:
392701157
ADMINISTRATOR:ALVAREZ, JEANFACILITY TYPE:
740
ADDRESS:492 E. FRISBEE LANETELEPHONE:
(209) 888-4080
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY: 6CENSUS: 4DATE:
11/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jean AlvarezTIME COMPLETED:
03:30 PM
NARRATIVE
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On 11/9/22 at 10:15am LPA Jensen arrived at facility to open a complaint investigation. LPA Jensen with Administrator Jean Alvarez and explained the purpose today's visit. During the course of the investigation, LPA Jensen discovered deficiencies and conducted a case management.

LPA Jensen reviewed a resident file for resident 1 (R1). The file for R1 had incomplete documentation including the LIC 9158, LIC 613C and LIC 603. In addition the resident file was consent forms, emergency contact and ID forms, immunization forms and safeguards for property and valuables.

LPA Jensen also determined that R1 and Resident 2 (R2) are bedridden. Both bedridden residents are on hospice care. LPA Jensen reviewed the facility sketch and there are no rooms designated for bedridden. LPA Jensen reviewed the STD 850 and determined there is no clearance for bedridden, only 6 non-ambulatory residents. LPA Jensen reviewed the LIC 200 and determined there is no request for bedridden capacity. LPA Jensen also observed a Inspection Record for Permit for voluntary fire sprinkler system dated 9/14/22.

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6. A civil penalty is also being assessed.

LPA Jensen observed the bedridden resident rooms to have exit doors and the facility had what appeared to be a fire sprinkler system.

An exit interview was conducted a copy of this report along with appeal rights was provided to the Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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 11/09/2022 03:20 PM - It Cannot Be Edited


Created By: Maja Jensen On 11/09/2022 at 02:48 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MOTHER MARY CARE HOME
FACILITY NUMBER: 392701157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2022
Section Cited
CCR
87633(l)

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...Nothing in this section [which deals with terminally ill residents and hospice care] shall be construed to relieve a licensed residential care facility for the elderly of its responsibility to notify the appropriate fire authority of the presence of a bedridden resident in the facility as required under subdivision (f) of Section 1569.72 and to obtain and maintain a fire clearance as required under Section 1569.149. This requirement was not met as evidenced by:
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Licensee will complete a new LIC 200 and update the facility sketch to reflect the rooms designated for bedridden residents. Licensee will email it to maja.jensen@dss.ca.gov. LPA Jensen will assist Licensee in completing the STD 850 and sending it to the Fire Marshal by 11/10/22.
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Based on LPA's review of records including resident file, LIC 200, facility sketch and STD 850 as well as the interview with Administrator Jean Alvarez, there are two residents that are bedridden and no fire clearance for bedridden residents. This poses an immediate risk to the health , safety and personal rights of residents in care.
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Type B
11/30/2022
Section Cited
CCR87506(a)

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(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident ...
This requirement was not met as evidenced by:
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The Licensee agrees to participate in the Technical Support Program offered by Community Care Licensing. LPA Jensen will forward the program information to the Licensee and the Licensee will make arrangements for engagement with the program by the Plan of Correction due date.
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Based on LPA Jensens review of records for resident 1 which contained multiple incomplete and missing documents. This poses a potential health, safety and personal rights risk to residents in care.
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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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


LIC809 (FAS) - (06/04)
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