Community Care Licensing

Document Has Been Signed on 12/08/2022 02:26 PM - It Cannot Be Edited

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:	12/08/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:41 PM
MET WITH:	Melva Taclay, Staff Venerando Gano, Administrator		TIME COMPLETED:	02:30 PM

SUPERVISORS NAME: Bennett Fong LICENSING EVALUATOR NAME: Daisy Panlilio LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022

Link to Parent Document Below:

FACILITY NAME: MAKANA HOUSE, THE	FACILITY NUMBER: 019200144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/27/2022 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.	1 2 3 4 5 6 7	By POC due date, Administrator agrees to submit to CCLD a copy of completed staff in-service training regarding safely storing prescribed and PRN medications in a safe and locked location.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by clients' unlocked medications which posed a potential health & safety risk to clients in care.	8 9 10 11 12 13 14	Administrator agreed to submit and self-certify that staff has read and will comply with Section 87465 refgulations.
Type B 12/27/2022 Section Cited CCR87465(h)(5)	1 2 3 4 5 6 7	Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.	1 2 3 4 5 6 7	By POC due date, Administrator agrees to submit to CCLD a copy of completed staff in-service training regarding ensuring residents’ medication are stored in their original containers
	8 9 10 11 12 13 14	This requirement was not met as evidenced by medication not stored in prescribed bottle which posed a potential health & safety risk to clients in care.	8 9 10 11 12 13 14	in compliance with Title 22 Section 87465 regulations.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Daisy Panlilio LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022

Link to Parent Document Below:

FACILITY NAME: MAKANA HOUSE, THE	FACILITY NUMBER: 019200144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/27/2022 Section Cited CCR 87705(f)(1)	1 2 3 4 5 6 7	The following shall be stored inaccessible to residents… (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).	1 2 3 4 5 6 7	By POC due date, Administrator agrees to submit to CCLD a copy of completed staff in-service training regarding locking tool sheds to ensure residents are not able to access tools
	8 9 10 11 12 13 14	This requirement was not met as evidenced by unlocked toolshed which posed a potential health & safety risk to clients in care	8 9 10 11 12 13 14	and other items that could constitute a danger to the residents.
Type B 12/27/2022 Section Cited CCR87211(a)(1)	1 2 3 4 5 6 7	Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events …	1 2 3 4 5 6 7	By POC due date, Administrator agrees to submit to CCLD a copy of completed staff in-service training on reporting requirements in compliance with Title 22 Section 87211.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by non submittal of incident report on client's unwitnessed fall which poses a potential health & safety risk to clients in care	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Daisy Panlilio LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022