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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200618
Report Date: 06/13/2023
Date Signed: 06/13/2023 12:43:57 PM

Document Has Been Signed on 06/13/2023 12:43 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: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:
06/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jeremy Usana, AdministratorTIME COMPLETED:
12:55 PM
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On 6/13/23 at 12:00 PM, Licensing Program Analyst (LPA) Greg Clark conducted a Case Management visit as a result of receiving a report from another agency. LPA met with Administrator, Jeremy Usana and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 113.1 degrees F in the kitchen sink. Resident's medications are kept locked in a medication cabinet. All over the counter medications were observed to have the residents name on them.

At 12:15 p.m. LPA observed in one of the resident bedrooms the closet door was difficult for the LPA to open. Administrator stated that the company handyman had bought new knobs for the closet but they didn't fit. The handyman is scheduled to return today to install new knobs on the closet door making it easier to open. LPA requested that administrator send LPA a picture of the new knobs once they are installed.

Fire extinguisher was observed to be full and last serviced on 10/23/22. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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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