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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200144
Report Date: 05/02/2022
Date Signed: 05/02/2022 05:57:41 PM

Document Has Been Signed on 05/02/2022 05:57 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:MAKANA HOUSE, THEFACILITY NUMBER:
019200144
ADMINISTRATOR:VENERANDO GANOFACILITY TYPE:
735
ADDRESS:32219 TERI COURTTELEPHONE:
(510) 441-1816
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 3DATE:
05/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Kristine Ocampo (Sanchez), House ManagerTIME COMPLETED:
06:10 PM
NARRATIVE
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On 5/2/2022 at 2:40PM, Licensing Program Analysts (LPAs) G. Luk and G. Clark arrived unannounced to conduct an Infection Control Inspection. LPAs met with House Manager, Kristine Ocampo (Sanchez).

Upon entry, LPAs' temperature was checked, but was not asked to fill out visitor's log. LPAs observed hand sanitizer at screening station. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPAs observed cough etiquette, signs & symptoms, and physical distancing are posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms.

During record review, LPAs observed visitors log. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPE, food supplies, and paper supplies are sufficient.

At 3:00PM, LPAs observed unlocked cleaning supply and gardening tools in the backyard. Staff locked up cleaning supply and gardening tools during inspection.

At 3:10PM, LPAs observed a hole on ceiling of bedroom 4, face plate plug next to front door was broken, and refrigerator shelves were broken. LPAs observed backyard has large quantity of items stored in common area including furniture, bikes, recycling, inoperable car, large TV, car batteries, mattresses, and a storage shed (assemble and still in box).

(Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
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 05/02/2022 05:57 PM - It Cannot Be Edited


Created By: Grace Luk On 05/02/2022 at 05:00 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: MAKANA HOUSE, THE
FACILITY NUMBER: 019200144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having unlocked cleaning supplies and gardening tools which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/03/2022
Plan of Correction
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Staff locked up cleaning supplies and gardening tools during inspection. Deficiency cleared.

Civil penalty of $250 is being assess for a repeat violation.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/02/2022 05:57 PM - It Cannot Be Edited


Created By: Grace Luk On 05/02/2022 at 05:00 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: MAKANA HOUSE, THE
FACILITY NUMBER: 019200144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 having broken items and backyard has large quantity of items stored in common area which poses a potential health and safety risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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House manager has agreed to repair ceiling in bedroom 4, face plate plug next to front door, and refrigerator shelves. House manager also agreed to remove items in the backyard including furniture, bikes, recycling, and broken car by POC date. House manager will send picture proof of repairs and removals to CCLD by POC date.
Type B
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by providing expired milk to clients which poses a potential health and safety risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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House manager has agreed to retrain all staff on food preparation and checking expiration dates and submit staff sign-in sheet to CCLD by POC date. House manager has agreed to purchase additional milk and provide a receipt to CCLD by 5/3/2022.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022


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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MAKANA HOUSE, THE
FACILITY NUMBER: 019200144
VISIT DATE: 05/02/2022
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At 3:30PM, LPAs observed expired milk and mayo. Staff informed LPAs that clients had milk this morning for breakfast.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC809 (FAS) - (06/04)
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