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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 134604792
Report Date: 05/08/2024
Date Signed: 05/08/2024 05:21:45 PM

Document Has Been Signed on 05/08/2024 05:21 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MACKENZIE CARE HOME IIIFACILITY NUMBER:
134604792
ADMINISTRATOR/
DIRECTOR:		HAMPTON, DEREKFACILITY TYPE:
735
ADDRESS:987 SHELBIE AVE.TELEPHONE:
(760) 460-1129
CITY:BRAWLEYSTATE: CAZIP CODE:
92227
CAPACITY: 4CENSUS: 0DATE:
05/08/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Derek Hampton and Raquel PreeceTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an announced pre-licensing visit. LPA was met by Applicants, Derek Hampton and Raquel Preece, and granted entry into the facility. Also present was Giovanna Lira, who will serve as House Manager.

The purpose of today’s visit was to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The fire inspection was completed on February 29, 2024, and the facility is approved for four (4) ambulatory clients.

During today's visit, LPA, accompanied by applicants, toured the facility and inspected all rooms. The facility was found to be in good repair with no pathway obstructions. Clients' bedrooms were observed to be clean and contained required furnishings. Toilets were found to be in working order. Hot water temperature in client bathroom measured at 115.6 degrees F. Hazardous and/or toxic chemicals were stored in the laundry room, which was locked and inaccessible to clients. Medications will be stored in a locked medicine cabinet, and client and staff records will be stored in a locked office. There was a first aid kit, manual, and emergency disaster kits present in the facility. The home has sufficient space in which to conduct activities. Fire extinguishers were observed in the facility. Hard-wired smoke and carbon monoxide detectors were present and operational. No pools or bodies of water were observed near or on the premises. According to the applicants, no firearms and/or ammunition were present or will be stored in the facility. A seven day supply of non-perishable food items and two day supply of perishable food items were present in the facility.

Pre-Licensing is complete, and no deficiencies were observed or cited during the visit. It is recommended that this facility be licensed pending final review and approval. An exit interview was conducted, and copies of this report and Applicant Rights were provided to the applicants at the conclusion of the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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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