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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200094
Report Date: 06/19/2023
Date Signed: 06/19/2023 02:06:41 PM

Document Has Been Signed on 06/19/2023 02:06 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MARY IMMACULATE RESIDENTIAL FACILITIES, INC.FACILITY NUMBER:
019200094
ADMINISTRATOR:EVITA R. MACARAEGFACILITY TYPE:
735
ADDRESS:4729 DARLENE COURTTELEPHONE:
(510) 477-8863
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Evita Macaraeg, AdministratorTIME COMPLETED:
02:20 PM
NARRATIVE
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On this day at around 9:50 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Administrator Evita Macaraeg (Certificate #6002201735). LPA explained to Administrator purpose of the visit.

LPA inspected the facility inside and out including but not limited to 3 client bedrooms, 2 bathrooms, kitchen, garage and backyard. There were 4 clients, 2 staff and Administrator observed during the visit. The facility is a Level 3 home vendorized by the Regional Center of the East Bay (RCEB).

There were no bodies of water observed. Facility was observed to be clean and odor free. There was sufficient perishable and non perishable foods. Medications were observed locked in a cabinet by the kitchen.
Carbon monoxide and smoke detectors were tested and observed operational. Fire extinguisher was observed full and was last serviced on 3/31/2023.

Last earthquake and fire drills were conducted In May 2, 2023. Surety bond in the amount of $3,000 is sufficient to cover amount of cash being handled at one time.

At around 10am, LPA observed hot water in one of the bathrooms measured at 127 degrees Fahrenheit.

LPA reviewed 3 client and 3 staff files. LPA interviewed 2 clients and 2 staff.

Type A deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Administrator. A copy of this report and Appeal Rights were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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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Document Has Been Signed on 06/19/2023 02:06 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/19/2023 at 01:09 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY IMMACULATE RESIDENTIAL FACILITIES, INC.
FACILITY NUMBER: 019200094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 having hot water meausre at 127 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2023
Plan of Correction
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Administrator adjusted hot water to 120F during the visit. Deficiency is cleared.
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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
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