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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004449
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:49:31 PM

Document Has Been Signed on 02/07/2023 01:49 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MAC RESIDENTIAL HOMEFACILITY NUMBER:
306004449
ADMINISTRATOR:EVELINA SCHAEFERFACILITY TYPE:
735
ADDRESS:705 N. GILBERT STREETTELEPHONE:
(714) 995-4131
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 4DATE:
02/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Freddie ManaladTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver. LPA met with Freddie Manalad, caregiver and explained the nature of the visit.

LPA Martinez accompanied by caregiver began the tour of the inside and outside of the facility. There are four clients in care and there are no active covid cases in the facility. LPA upon entry observed there was one client having lunch. The remainder of the clients were out in the community. Facility has a sign-in procedure in the facility in place. The facility has a two day supply of perishables and seven day supply of non-perishable foods available. All bathrooms observed to have a supply of soap. LPA toured client’s bedrooms, all bedrooms observed to have all required components. The facility is equipped with sufficient hand hygiene supplies, cleaning and disinfecting supplies. Facility has an emergency food supply and water supply as well. Personal protective equipment (PPE) supply available. Facility has a secure location for client’s medication and inaccessible to client’s in care. LPA toured the outside of the facility and shaded areas for client’s use. LPA observed required department postings, covid precautionary postings, and hand washing signs throughout the facility. Facility has required Emergency Disaster Plan posted. Facility has a Mitigation Plan on file with CCLD.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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