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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200256
Report Date: 03/14/2023
Date Signed: 03/14/2023 04:59:20 PM

Document Has Been Signed on 03/14/2023 04:59 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: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: 6DATE:
03/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Leandro Lacson, AdministratorTIME COMPLETED:
05:05 PM
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On 3/14/2023 at 12:55PM, Licensing Program Analysts (LPAs) L. Hall and L. Alexander conducted an unannounced annual required inspection. LPAs met with Leandro Lacson, Administrator, and explained the purpose of the visit. LPAs toured the facility with Leandro Lacson, Administrator. The administrator currently holds a certificate (#6041545735) that expires on 7/21/2024. The facility’s fire clearance was approved for six (6) ambulatory clients.

Upon arrival LPAs observed three (3) staff and one (1) client. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of eight (8) total bedrooms which six (6) are occupied by the clients and two (2) by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 110.1 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. PPE and paper goods are sufficient.

Continued on LIC9099C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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: MAC'S HOME
FACILITY NUMBER: 079200256
VISIT DATE: 03/14/2023
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Continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 12/2/2021. Emergency Disaster Plan was last posted on 11/14/2022. First aid kit was observed to be complete. Fire drill was last conducted on 11/12/2022.

Four (4) of six (6) Staff records were reviewed, and all staff have criminal record clearance. All six (6) clients records reviewed were current and complete. LPAs also review P & I for two (2) clients. The other four (4) clients handle their own P & I.

The following forms to be updated and submitted to CCLD by 03/21/2023:

LIC 500 Personnel Report
LIC 9020 Client roster
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond

No deficiencies cited during visit.

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

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC809 (FAS) - (06/04)
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