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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004449
Report Date:
02/28/2022
Date Signed:
02/28/2022 12:22:30 PM
Document Has Been Signed on
02/28/2022 12:22 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
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
MAC RESIDENTIAL HOME
FACILITY NUMBER:
306004449
ADMINISTRATOR:
EVELINA SCHAEFER
FACILITY TYPE:
735
ADDRESS:
705 N. GILBERT STREET
TELEPHONE:
(714) 995-4131
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92801
CAPACITY:
6
CENSUS:
5
DATE:
02/28/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:31 AM
MET WITH:
Freddie Manalad
TIME COMPLETED:
12:41 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry. LPA explained the reason for the visit. LPA and staff and toured the facility. LPA inspected the client bedrooms. LPA observed all of the client rooms had the required furnishings. Smoke detectors/carbon monoxide detectors tested operational. Hot water temperature measured 120.0 degrees Fahrenheit in both client bathrooms. LPA observed clean linens in the linen closet. LPA and staff toured the kitchen. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. The kitchen is clean and organized. LPA observed knives are kept locked in a kitchen drawer. Cleaning supplies are kept locked under the sink. Medication is kept locked in a filing cabinet. LPA and staff toured the backyard. The exit gate is operational. No bodies of water observed. No obstacles or hazards observed. LPA and staff toured the garage. The garage is kept locked and used for storage. Facility has a mitigation plan that is pending approval. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME
:
Luz Adams
LICENSING EVALUATOR NAME
:
Joseph Alejandre
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/28/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/28/2022
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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