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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200094
Report Date: 05/09/2024
Date Signed: 05/09/2024 01:29:32 PM

Document Has Been Signed on 05/09/2024 01:29 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/
DIRECTOR:		EVITA R. MACARAEGFACILITY TYPE:
735
ADDRESS:4729 DARLENE COURTTELEPHONE:
(510) 477-8863
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Evita MacaraegTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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On this day at around 10:40 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Administrator Evita Macaraeg (Certificate #6002201735 expiration 4/25/2025). 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 5 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 5/1/2024 . LPA reviewed P&I money and log with Administrator.

Last earthquake and fire drills were conducted In May 4, 2024. Surety bond in the amount of $3,000 is sufficient to cover amount of cash being handled at one time.

LPA reviewed 5 client and 4 staff files. All staff are fingerprint cleared and associated to the facility. Staff have current First Aid and CPR training. LPA interviewed 1 client and 2 staff.

No deficiencies were noted during the visit.


SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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