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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200618
Report Date: 09/27/2022
Date Signed: 09/27/2022 11:48:45 AM

Document Has Been Signed on 09/27/2022 11:48 AM - 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:MACRI'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
079200618
ADMINISTRATOR:POLANCOS, ANASTACIO BFACILITY TYPE:
737
ADDRESS:4680 NEROLY ROADTELEPHONE:
(925) 679-4430
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 4DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Anastacio Polancos, Administrator & Jeremy Usana, assistant administratorTIME COMPLETED:
12:05 PM
NARRATIVE
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On 9/27/2022 at 9:50AM, Licensing Program Analyst (LPA) L. Ibo conducted an infection control annual inspection and met with S3, LPA informed S3 the purpose of the visit. At around 10:00AM S2 arrived at the facility and around 10:45AM S1 arrived at the facility to join S2 on the facility inspection. The facility is licensed as a Enhanced Behavioral Support Home – ARF. LPA observed 1 client during the visit, S2 stated that 3 clients are at the day program.

LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. Facility has a completed mitigation plan and infection control plan.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 70 degrees Fahrenheit. A certified Administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.

LPA observed the following:
· Unlocked disinfectants accessible to clients in care

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with S1 and S2.



Exit interview conducted and appeal rights copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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 09/27/2022 11:48 AM - It Cannot Be Edited


Created By: Leslie Ibo On 09/27/2022 at 11:09 AM
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: MACRI'S ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 079200618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having the unlocked cabinet that contained disinfectants and cleaning products that is accessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2022
Plan of Correction
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Staff locked the cabinet. Administrator agreed to conduct in-service training for all staff regarding the citation cited above, a copy of training with staff names and signature need to be submitted to CCL office by 9/30/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022


LIC809 (FAS) - (06/04)
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