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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200618
Report Date: 12/24/2024
Date Signed: 12/24/2024 01:01:03 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
08/26/2024 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240826163252
FACILITY NAME:MACRI'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
079200618
ADMINISTRATOR:USANA, JEREMY NFACILITY TYPE:
737
ADDRESS:4680 NEROLY ROADTELEPHONE:
(925) 679-4430
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:4CENSUS: 4DATE:
12/24/2024
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Anastacio Polancos, CaregiverTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff caused injury to resident.
Staff yelled at resident
INVESTIGATION FINDINGS:
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On 12/24/2024 at 12:10PM Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Anastacio Polancos Caregiver. Jeremy Usana, Administrator arrived at 12:30PM, and LPA explained the purpose of the visit.

Allegation: Staff caused injury to resident.
During the course of investigation, LPA interviewed the complainant (W1) and three (3) staff members. LPA could not interview client (C1) do to C1 being nonverbal. LPA also reviewed C1’s file including dangerous propensity report and individual program planning (IPP). Interviews conducted and file review document C1 has a long history of Self-Injurious Behavior (SIB).

Allegation: Staff yelled at resident.
During the course of investigation and Interviews with staff indicated that staff treat clients with dignity and respect. Staff have not witnessed staff members being rude or mistreating clients and stated that staff are trained to redirect clients when a behavior occurs.
Continued on LIC9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
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 2
Control Number 15-AS-20240826163252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MACRI'S ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 079200618
VISIT DATE: 12/24/2024
NARRATIVE
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Continued from LIC9099.

Based upon the interviews during the investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2