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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200256
Report Date: 06/18/2024
Date Signed: 06/18/2024 04:05:06 PM

Document Has Been Signed on 06/18/2024 04:05 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/
DIRECTOR:		LEANDRO LACSONFACILITY TYPE:
735
ADDRESS:4466 MIRA LOMA DRIVETELEPHONE:
(925) 267-4886
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
06/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Aiamaureen Gatia, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 6/18/2024 at 3:30pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Aiamaureen Gatia, Direct Support Professional, and explained the reason for the visit. LPA spoke with Administrator, Leandro Lacson, via telephone.

LPA L. Hall was conducting a complaint investigation (15-AS-20240618101129) on 6/18/2024, and was informed that Administrator was out-of-town and did not leave a designated substitute that meets administrator qualifications.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency 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
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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Document Has Been Signed on 06/18/2024 04:05 PM - It Cannot Be Edited


Created By: Laura Hall On 06/18/2024 at 03:41 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: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2024
Section Cited
CCR
85064(f)

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85064 Administrator Qualifications and Duties (f) When the administrator is absent from the facility there shall be coverage by a designated substitute... who shall be capable of... management and administration of the facility in compliance with applicable law and regulation. This requirement was not met as evidence by:
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Administrator agreed to read and review regulation 85064 and submit a self-certification that it has been reviewed, and going forward the administrator will abide by the regulation to CCLD by POC date.
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Based on observation and interview the Licensee did not comply with the regulation above in having a qualified substitute in his absence which poses a potential health and safety risk for 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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