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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200256
Report Date: 03/27/2024
Date Signed: 03/27/2024 05:40:42 PM

Document Has Been Signed on 03/27/2024 05:40 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:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Lejani Era, Direct Support ProfessionalTIME COMPLETED:
05:50 PM
NARRATIVE
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On 3/27/2024 at 2:50PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Lejani Era, Direct Support Professional, and explained the purpose of the visit. 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.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, 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 72 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 108.8 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. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Continued on LIC9099C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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: MAC'S HOME
FACILITY NUMBER: 079200256
VISIT DATE: 03/27/2024
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Continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 5/30/2023. Emergency Disaster Plan was last posted on 6/1/2023. First aid kit was observed to be complete. Fire drill was last conducted on 2/29/2024.

LPA reviewed four (4) staff records all were current and complete. All six (6) clients records reviewed, current, and complete. LPA also review P & I and a sample of medication.

The following forms to be updated and submitted to CCLD by 4/3/2024:

LIC 500 Personnel Report
LIC 9020 Client roster
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC610D Emergency disaster plan (last page)

LPA observed the following deficiencies:
  • At 3:00pm, LPA observed unlocked kitchen drawer with medication.
  • At 4:28pm, LPA observed mice dropping in food pantry.
  • At 4:35pm, LPA observed tires blocking exit door in garage.


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/27/2024 05:40 PM - It Cannot Be Edited


Created By: Laura Hall On 03/27/2024 at 05:19 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: MAC'S HOME
FACILITY NUMBER: 079200256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having medication inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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2
3
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Caregiver immediately locked medication in medication cabinet. Deficiency cleared during visit.
Type A
Section Cited
CCR
80072(7)
80072 Personal Rights

(7) Not to be locked in any room, building, or facility premises by day or night

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having a tires blocking exit door in garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Administrator agreed to remove tires and submit photo to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2024 05:40 PM - It Cannot Be Edited


Created By: Laura Hall On 03/27/2024 at 05:19 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: MAC'S HOME
FACILITY NUMBER: 079200256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in have mice droppings in pantry which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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Administrator agreed to hire exterminator and submit invoice to CCLD by POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


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: 03/27/2024
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Continued from LIC809C.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
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