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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200256
Report Date: 06/18/2024
Date Signed: 06/18/2024 04:01:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20240618101129
FACILITY NAME:MAC'S HOMEFACILITY NUMBER:
079200256
ADMINISTRATOR:LEANDRO LACSONFACILITY TYPE:
735
ADDRESS:4466 MIRA LOMA DRIVETELEPHONE:
(925) 267-4886
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 5DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Aiamaureen Gatia, Direct Support ProfessionalTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Client assaulted another client at the facility
INVESTIGATION FINDINGS:
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On 6/18/2024 at 12:40pm, Licensing Program Analyst (LPA) L. Hall arrived to conduct an initial 10-day complaint investigation and deliver complaint findings. LPA met with Aiamaureen Gatia, Direct Support Professional (DSP). Administrator, Leandro Lacson, was out-of-town. LPA spoke with Administrator via telephone.

During the investigation LPA interviewed three (3) staff, two (2) clients, obtained and reviewed the after visit summary for C2, and the physician's report, dangerous propensities, admission agreement, Individual Program Plan dated 10/4/2021 (IPP), incident reports for C1, police report number and personal report (LIC500). Based on interviews the incident occurred around 6:00pm on 6/17/2024 and all stated C1 was the aggressor in the incident. Both staff and clients stated C1 went after C2. The staff

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20240618101129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MAC'S HOME
FACILITY NUMBER: 079200256
VISIT DATE: 06/18/2024
NARRATIVE
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Continued from LIC9099.

was not able to pull C1's hands from around C2's neck. S2 stated she ran to neighbors for assistance to call 9-1-1. Pittsburg Police Officers, the fire department and ambulance services arrived. C1 returned back into the home and was taken away. C2 was treated for bruised and returned back to the facility the same evening. Based on the investigation the above allegation is unsubstantiated.

The deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240618101129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAC'S HOME
FACILITY NUMBER: 079200256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2024
Section Cited
CCR
80072(a)(3)
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(a) ...each client shall have personal rights which include, but are not limited to, the following: (3) To be free from... punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature... This requirement was not met as evidence by:
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Administrator agreed to implement a plan that when or if C1 returns to the facility how will the clients keep safe. The plan shall be submitted to CCLD by POC date.
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Based on interviews the Licensee did not comply with the section cited above in keeping C2 free from infliction of pain, which poses a potential health and safety risk to persons in care.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3