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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200144
Report Date: 04/10/2024
Date Signed: 04/10/2024 02:49:28 PM

Document Has Been Signed on 04/10/2024 02:49 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/
DIRECTOR:		VENERANDO GANOFACILITY TYPE:
735
ADDRESS:32219 TERI COURTTELEPHONE:
(510) 441-1816
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 3DATE:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Venerando GanoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On this day at around 11:55 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct an annual required inspection. LPA was met by staff Luzviminda Bumanglag and Kristine Sanchez. LPA explained to the staff 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.

There was one client at the facility observed upon LPA arrival. There were 3 staff on shift during the visit.

LPA inspected the facility inside and out including but not limited to 3 client bedrooms, 2 bathrooms, kitchen, dining and backyard. Facility was observed to be clean and with sufficient lighting. There were no bodies of water observed. There was sufficient supply of perishable and non perishable foods observed. Warm blankets, towels and sheets were observed to be sufficient and in good repair. A fire extinguisher that appeared full and purchased on 7/12/2023 was observed. Dual carbon monoxide and smoke detectors were tested and observed functional. First aid kit was observed complete and current.

Medications were observed locked in a cabinet in the hallway.

At 12:30 pm, LPA reviewed P & I money and log with Sanchez. The facility has sufficient amount of surety bond to cover amount of cash being handled at one time. continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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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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: 04/10/2024
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At 12:45 pm, LPA reviewed 3 client files and 3 staff files.

At 2:30 pm, LPA interviewed C3 and staff.

Last fire drill was conducted on 3/18/2024 and last earthquake drill was conducted on 1/7/2024.

The following deficiencies were observed:
  • Hot water measured at 122.8 F in the shared bathroom.
  • Comet was observed in a cabinet under the sink unlocked


Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/10/2024 02:49 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 04/10/2024 at 02:27 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: 04/10/2024

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 in having Comet cleanser unlocked and accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Comet was locked during the visit. The deficiency is cleared.
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 in the common bathroom at 122.8 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Hot water was adjusted to 119 degrees Fahrenheit during the visit. This deficiency is cleared.
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: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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