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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000839
Report Date: 01/09/2023
Date Signed: 01/09/2023 11:10:41 AM

Document Has Been Signed on 01/09/2023 11:10 AM - 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:MARY FRANCES HAT RESIDENTIAL FACILITYFACILITY NUMBER:
397000839
ADMINISTRATOR:LAURA REEVESFACILITY TYPE:
740
ADDRESS:14381 E. SARGENT ROADTELEPHONE:
(209) 334-6454
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 6CENSUS: 4DATE:
01/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Laura Reeves - AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility after getting temperature checked and COVID-19 precautions. Facility is licensed to serve a total capacity of six non-ambulatory residents, currently there are four residents.

LPA and administrator toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for residents is maintained at 72 degree Fahrenheit. The hot water temperature was observed to be 109.7 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7 day non-perishables and 2 day perishables foods.
LPA observed smoke detectors are interconnected with the fire department. Carbon monoxide is in operating condition. Fire extinguishers were last serviced on 2/7/2022. LPA observed mitigation plan completed. First aid kit observed to be complete. Fire drill was last conducted on 12/17/2022. LPA reviewed three (3) staff records and two (2) resident records. All files were complete. Staff are fingerprint cleared and first aid certified. Liability Insurance expires 3/1/2023.
LPA observed medications and the MARS sheets. Medications appear to be documented appropriately.

LPA received the following updated documents on January 9, 2023: Administrator Certificate, Articles of Incorporation, Liability Insurance, LIC 308 - Designation of Administrative Responsibility, and LIC 610-E Emergency Disaster Plan.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited.

Exit interview conducted with administrator and a copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2023
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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