019200144-5-3-2023-15-AS-LFOA-CRGT6Y-20230503142754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200144
Report Date: 04/27/2023
Date Signed: 05/03/2023 02:28:01 PM

Document Has Been Signed on 05/03/2023 02:28 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, THE		FACILITY NUMBER:	019200144
ADMINISTRATOR:	VENERANDO GANO		FACILITY TYPE:	735
ADDRESS:	32219 TERI COURT		TELEPHONE:	(510) 441-1816
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY: 4		CENSUS: 3	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Venerando Gano, Administrator		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day at around 9:35 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct annual required inspection. LPA was met by staff Luzviminda Bumanglag and explained the purpose of visit. Administrator Venerando Gano arrived at the facility at a later time. The facility is a Level 4i home vendorized by the Regional Center of the East Bay (RCEB). It has an approved fire clearance for 4 ambulatory clients. Upon arrival, LPA observed a client getting ready for day program. Two other clients were in their respective day programs. There were 2 staff on shift during the visit. LPA inspected the facility inside and out including but not limited to client 3 client bedrooms, 2 bathrooms, kitchen, dining and backyard. Facility was observed clean and with sufficient lighting. There was no body of water observed. Hot water measured at 113 F in the shared bathroom. There was sufficient supply of perishable and non perishable foods observed. Fire extinguisher was observed full that was last inspected on 8/2/2022. Carbon monoxide and smoke detector were tested and observed functional. Medications were observed locked in a cabinet in the hallway. * continuation on Lic 809C*

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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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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: 04/27/2023

NARRATIVE

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Facility has an approved mitigation plan. Facility has a surety bond in the amount of $3,000 which is sufficient to cover amount of money being handled at one time.

At 10:15 am, LPA reviewed Medication Administration Record (MAR) and medications for Client 1 (C1) and Client 2 (C2).

At 10:40 am, LPA reviewed P & I money and log. At 11:25 am, LPA reviewed 2 resident files, Administrator and 2 staff files.

At 12:40 pm, LPA reviewed First /aid kit. Last fire drill was conducted on 4/16/2023.

At 1:50 pm, LPA interviewed C1 and C2.

There were no deficiencies observed during inspection.

Exit interview was conducted with the Administrator and a copy of this report was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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