<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880545
Report Date: 10/16/2023
Date Signed: 10/16/2023 11:52:56 AM

Document Has Been Signed on 10/16/2023 11:52 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MAC'S HOME #1FACILITY NUMBER:
331880545
ADMINISTRATOR:PETERS, STEPHANIEFACILITY TYPE:
735
ADDRESS:887 ARIA RDTELEPHONE:
(951) 305-6288
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 4CENSUS: 4DATE:
10/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Stephanie Peters, LicenseeTIME COMPLETED:
12:00 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
On October 16, 2023, the Department held an informal meeting to discuss issues and concerns regarding the facility. In attendance was Licensing Program Manager (LPM), Jazmond Harris, Licensing Program Analysts (LPA)s, Yolanda Delgado and Javina George, and Licensee's Lansdale Peters, and Stephanie Peters, as well as the facility administrator Solomon Chukwu.

The following was discussed:

Staffing:


-Issues and concerns were discussed regarding the attributes to staffing changes. The facility personnel roster and any necessary changes will be made, including the change of administrator. The RO will assist the facility in ensuring all necessary staff are associated/disassociated due to ongoing issues with the Guardian System.

In addition the facility is actively hiring, however with current staffing the facility is able to meet the required ratio of 3:1.
-Interview process
-Training
-Increase of Administrator oversight
-Record keeping

Resources:
-Technical Support Program (TSP). The Licensee's expressed interest in assistance with record keeping, LPA will submit the necessary paperwork.
-Care Tools to assist with preparing for department visits

An exit interview was conducted, a copy of this report, and appeal rights were provided to the Licensee, Stephanie Peters.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
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 1