134604599-8-16-2022-08-AS-DNGN-CHCLQS-20220816085759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 134604599
Report Date: 08/15/2022
Date Signed: 08/16/2022 08:58:32 AM

Document Has Been Signed on 08/16/2022 08:58 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	MACKENZIE CARE HOME II		FACILITY NUMBER:	134604599
ADMINISTRATOR:	RAQUEL PREECE&DEREKHAMPTON		FACILITY TYPE:	735
ADDRESS:	484 CORRAL CT		TELEPHONE:	(760) 460-1129
CITY:	IMPERIAL	STATE: CA	ZIP CODE:	92251
CAPACITY:	4	CENSUS: 0	DATE:	08/15/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Applicants Raquel Preece and Derek Hampton		TIME COMPLETED:	02:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit with applicants Raquel Preece and Derek Hampton.

The facility fire clearance was granted on July 11th, 2022 and reflects that the facility is approved for four (4) ambulatory clients.

During today’s visit, LPA, accompanied by the applicants, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Client bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 75 F. Water temperatures were also compliant: Kitchen Tap was 108 F, Bathroom #1 was 111.7 F, and Bathroom #2 was 115 F.

The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future client use. Refrigerator temperature was 37 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and client activities. The facility has locked areas for storage of medication and confidential client and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Per the applicant, no firearms or ammunition are or will be stored at the facility.

[CONTINUED ON LIC 812-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MACKENZIE CARE HOME II	FACILITY NUMBER: 134604599
	VISIT DATE: 08/15/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809]

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Two (2) fire extinguishers and one (1) first aid kit were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. The applicants passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. Preece and Hampton were advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the applicants, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2