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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880545
Report Date: 12/18/2024
Date Signed: 12/18/2024 03:19:39 PM

Document Has Been Signed on 12/18/2024 03:19 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MAC'S HOME #1FACILITY NUMBER:
331880545
ADMINISTRATOR/
DIRECTOR:		PETERS, STEPHANIEFACILITY TYPE:
735
ADDRESS:887 ARIA RDTELEPHONE:
(951) 305-6288
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 4CENSUS: 2DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Ashanti White, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
03:25 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), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. On today’s visit the LPA met with Direct Support Professional (DSP), Ashanti White. White contacted Administrator Lansdale Peters via telephone and notified him of the purpose for the visit.

INFECTION CONTROL: The facility has an infection control plan in place that is being reviewed regularly for any needed updates and/or changes. Staff reported the plan is being followed whenever there are any clients in care who present with infections. PHYSICAL PLANT AND ENVIRONMENTAL SAFETY: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Clients appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. No pool or other body of water was observed on the property. Staff reported there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. The smoke and carbon monoxide alarms were tested and found to be operable. The interior and exterior areas of the home were observed to be clean and safe. Operational Requirements: The Licensee has secured and appears to be maintaining the approved fire clearance. Proof of training in reporting requirements was observed on file. The licensee appears to be providing for all client's activities of daily living needs, including supervision. A plan for providing clients with activities is being followed. STAFFING: Facility personnel appear to be competent to provide the necessary services to meet individual client needs. Review of the facility's staff schedule revealed one to two staff members are scheduled per shift. Staff reported there is currently sufficient staffing available to meet client needs. The staff schedule revealed night staff are available to provide clients with care and supervision. Staff reported night staff are on call and on the premises, as required. Staff are trained in emergency procedures.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAC'S HOME #1
FACILITY NUMBER: 331880545
VISIT DATE: 12/18/2024
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
PERSONNEL RECORDS - TRAINING: The Administrator appears to be on the premises the sufficient number of hours to manage and administer the facility. Administrator has an active Administrator's Certificate. All staff members have had health screenings completed with TB test results listed. Staff present had the required criminal record clearances. Documentation of criminal record clearances were observed on file. Staff files had required training; including, but not limited to, DSP training, medication training and First Aid/CPR training. CLIENTS RIGHTS - INFORMATION: An internet accessible device is available for client use. Food Service: The LPA inspected the facility's kitchen areas and food supply. Staff reported three meals per day are provided. The LPA observed all food to be of good quality. All readily perishable foods and beverages were stored in covered containers at appropriate temperatures. Soaps, detergents, cleaning compounds and similar substances were stored in areas separate from food supplies. All kitchen areas were kept clean and free of litter, rodents, vermin, and insects. According to staff, there are no clients in care who require a modified diet. It was reported that the staff members who engage in food preparation and services follow personal hygiene and food services sanitation practices. Kitchen ware was observed to be in good condition and sufficient for each clients in care. Kitchen equipment and appliances were observed to be in working order. CLIENT RECORDS - INCIDENT REPORTS: All clients had individual written admission agreements on file. Written certification regarding no objections to the placement of the clients by the Inland Regional Center (IRC) was observed on file. Additional required records were observed to be on file and complete, including, but not limited to, medical assessments, Individual Program Plans (IPPs), and centrally stored medication and destruction records. Health Related Services: The licensee is ensuring client's first aid and other needed medical or dental needs are being met for each client in care. Clients are being assisted with administration of prescribed medications. According to staff, all clients are able to communicate their symptoms clearly, if they are prescribed PRN medications. Client medications were observed to be appropriately labeled. Medications were observed to be centrally stored in a safe and locked area. Staff are assisting clients who require assistance with bowel and/or bladder incontinence. INCIDENTAL MEDICAL SERVICES: According to staff, there are no clients in care who have a Restricted or Prohibited Health Condition. DISASTER PREPAREDNESS: The facility has an emergency plan on file and proof of emergency drills was observed to be completed. EMERGENCY INTERVENTION: According to staff, manual restraint and/or seclusion procedures are not being practiced at the facility. EXIT: The home appears to be operating within regulatory requirements. This report was reviewed with Administrator Peters, who arrived at the conclusion of the visit, and a copy was provided. No deficiencies were cited at time of inspection.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2