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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200144
Report Date: 03/12/2025
Date Signed: 03/12/2025 02:59:57 PM

Document Has Been Signed on 03/12/2025 02:59 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:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Venrando GanoTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On this day at around 12:25 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA was met by staff Luzviminda Bumanglag. LPA explained to Bumanglag the purpose of visit. Administrator Venerando Gano arrived at the facility at around 12:50 pm.

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 was one 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 area and backyard. Facility was observed to be clean and odor free. 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 7/24/24 was observed. Dual carbon monoxide and smoke detectors were tested and observed functional. First aid kit was observed complete and current.
Hot water measured at 110.7 Fahrenheit. Medications were observed locked in a cabinet in the hallway.

At 12:50 pm, LPA reviewed P & I money and log with Bumanglag. The facility has sufficient amount of surety bond to cover amount of cash being handled at one. At 1:05 pm, LPA reviewed medications and Medication Administration Record (MAR).

At 1:35 pm, LPA reviewed 3 staff files and 3 client files. All staff are fingerprint cleared and associated to the facility. They have current first aid and CPR training.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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: 03/12/2025
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The last fire drill was conducted on 2/15/2025 and the last earthquake drill was completed on 12/14/2024.

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

The following documents need to be submitted to CCL by 3/21/2025:
  • Infection Control Plan
  • Emergency Disaster Plan
  • Surety bond
  • Liability insurance
  • Lic 500 Personnel Report
  • Lic 9020 Roster of Clients
  • Registration/insurance of vehicles/driver's license


Exit interview was conducted with Luzviminda Bumanglag, who was authorized by the Administrator to sign the report. Appeal Rights and a copy of this report was provided.


SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2025 02:59 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/12/2025 at 02:37 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: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review conducted, the licensee did not comply with the section cited above in not having an updated medical assessment for which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
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By POC date, the Administrator states C2's updated medical assessment will be submitted to CCL.
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: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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