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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 11/08/2024
Date Signed: 11/08/2024 03:07:28 PM

Document Has Been Signed on 11/08/2024 03:07 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:MOTHER MARY CARE HOMEFACILITY NUMBER:
392701157
ADMINISTRATOR/
DIRECTOR:		ALVAREZ, JEANFACILITY TYPE:
740
ADDRESS:492 E. FRISBEE LANETELEPHONE:
(209) 888-4080
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY: 6CENSUS: 0DATE:
11/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Arvin AlvarezTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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LPA Jensen arrived at facility unannounced to conduct a case management. LPA Jensen met with Arvin Alvarez, the son of the Licensee and explained the purpose of the visit.

The Licensee previously notified the department that she is not currently taking clients in order to tend to personal matters. The Licensee assisted all residents in relocating and provided the department a resident roster and relocation information. LPA Jensen was granted access to the facility. LPA Jensen inspected all rooms in the facility and verified there are no clients in care. The Licensee will notify the Department when she wishes to resume operations. No further action required by the licensee at this time.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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