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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200618
Report Date: 06/10/2025
Date Signed: 06/10/2025 03:52:50 PM

Substantiated


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
03/04/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250304134220
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:
06/10/2025
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Anastacio Polancos, Caregiver TIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff left resident unsupervised for an extended period of time.
INVESTIGATION FINDINGS:
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On 06/10/2025 at 1:50PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegation above. LPA met with Caregiver, Anastacio Polancos and explained the purpose of the visit. administrator, Jeremy Usana arrived at 2:19PM, LPA explained the purpose of the visit.

During the course of the investigation, LPA T. Syess-Gibson conducted interviews with staff and complainant. Staff schedule, staff roster with phone numbers, client (C1) Individual Program Plan (IPP), Individual Behavioral Support Plan, RCEB vendor special incident report, and facility’s list of duties for staff 1 and staff 2 for when caring for C1 was obtained and reviewed.
Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025
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 3
Control Number 15-AS-20250304134220
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: 06/10/2025
NARRATIVE
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Continued from LIC9099

Interviews with staff and complainant revealed client has a two to one (2:1 staffing ratio) and client (C1) was left in a van alone while staff (S1) experienced a medical emergency. Record review revealed C1 has a two to one (2:1 staffing ratio) during AM and PM shifts. Record review also revealed, Licensee did not report the incident to Community Care Licensing (CCL).

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted with Jeremy Usana. A copy of this report and appeal rights provided.

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

DATE: 06/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250304134220
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2025
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision(a)In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services...This requirement is not met as evidence by:
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Licensee/Administrator will implement a plan indicating the prevention of leaving clients unsupervised and submit to CCL by POC date.
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Based on investigation, licensee did not comply with the section cited above by leaving client alone in the van without supervision which posed a health and safety risk to the 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3