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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701157
Report Date: 08/18/2025
Date Signed: 08/18/2025 04:44:51 PM

Document Has Been Signed on 08/18/2025 04:44 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: 5DATE:
08/18/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Jean AlvarezTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 8/18, at 11:30 pm. Licensing Program Analyst (LPA) Noel Wolf Petersen arrived unannounced to follow up with some changes to policy the facility was asked to make as part of a previous Plan of Corrections. LPA met with the adminstrator Jean Alvarez and explained the purpose of the visit.
The issues are addressed as follows.
A-Toxics under the sink are now locked in the locked staff room.
A- All staff are firgerprinted and associated via gaurdian
A- medication training is complete for most employees, current MARs are up to date with available medication, but PRN documentation records are not up to date, the LPA is writing a new citation for it.
B- CPR/First Aid is complete,
B- 2 days of Perishable Food is in compliance, 7 days of non-perishable is in compliance
B- Continuing training is complete for non-dementia folks which the citation was refering to, one resident does have dementia now, therefore extended dementia training is required, and the LPA is writing a new citation for asking that training to be completed.

Administrator following documents were reviewed:
License: The License is for 6 non-ambulatory, there is one person who is bedridden in the facility currently, and the last fire clearance says 4 non-amb and 2 bedridden, dated 12/6/22. The LPA will ensure the license gets updated and sent to the administrator.

Continued on C page
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2025
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: MOTHER MARY CARE HOME
FACILITY NUMBER: 392701157
VISIT DATE: 08/18/2025
NARRATIVE
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Performed a physical inspection and record review of 5 client and 5 staff files. 2 staff interviews and 2 client interviews.

Citations issued on following D page

An exit interview was conducted, a copy of the appeal rights were left with the administrator, a copy of the report was read and left with the administrator
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2025 04:44 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 08/18/2025 at 04:02 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: MOTHER MARY CARE HOME
FACILITY NUMBER: 392701157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2025
Section Cited
CCR
87465(c)(3)

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87465 Incidental Medical and Dental Care (c) ...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided...
(3) A record of each dose is maintained in the resident's record...the date and
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Administrator will send in a picture of documentation demonstration they understand how to document the PRN medication, by the POC.
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time the PRN medication was taken, the dosage taken, and the resident's response. The requirement was not met as evidenced by: interview and record review showing multiple 3+ instances of given PRN's without documentation. This constitutes an immediate health and saftey risk to persons in care
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Type B
09/18/2025
Section Cited
HSC1569.626(a)(1)

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California Health and Saftey code 1569.626 (a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:(1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins
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The Licensee will do a 12h inservice on dementia, then submit a progress report on as 9/18/25, The training should be started for everyone, and at least one person on each shift should be done by 9/18/25.
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independently... All 12 hours shall be devoted to the care of persons with dementia.
This requirement was not met as evidinced, by record review. this constiutes a potential health and saftey risk to persons 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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2025


LIC809 (FAS) - (06/04)
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