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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880545
Report Date: 04/20/2023
Date Signed: 04/20/2023 01:15:30 PM

Document Has Been Signed on 04/20/2023 01:15 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, 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:
(909) 910-9114
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 4CENSUS: 4DATE:
04/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Direct Service Professional II Felicia MastersTIME COMPLETED:
01:20 PM
NARRATIVE
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On 04/20/2023 at 09:45 AM, Licensing Program Analyst (LPA) Melody Brown met with Direct Service Professional II Felicia Masters to initiate a Case Management Visit. The investigation consisted of interviews and a review of pertinent documentation.

During today's visit, LPA Brown toured the facility. Residents in care were present during the visit. LPA Brown observed no health and/or safety hazards inside the facility. LPA Brown inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Brown observed sufficient staff present at the facility to provide care. LPA Brown inspected facility food supplies and observed more than three (3) days’ supply of perishable and more than seven (7) days’ supply of non-perishable food. The needs of the residents in care appear to be met during this inspection.

During the facility visit last 04/20/2023 at 09:45 AM, LPA Brown reviewed documents and interviewed staffs and observed that Staff #3 (S3), Staff # 7 (S7) and Staff # 8 (S8) have a current criminal background clearance but S3, S7 and S8 are not currently associated to the facility. Staff interviews and records review indicated S3 had been working at the facility since 03/11/2022, S7 started working at the facility last 03/22/2023 but interviews and records review revealed S7 worked two (2) days at the facility last 03/31/2023 and 04/18/2023 and S8 had been working at the facility last 10/27/2022 and interview and records review indicated that S8 worked at the facility last 11/18/2022, 03/03/2023, 03/10/2023, 04/07/2023 and 04/17/2023. LPA Brown informed DSP II Masters that deficiency will be issued as this pose potential health, safety and personal rights risks to residents in care.

Civil Penalty was assessed with the amount of $500.00 for S3 and S8 and $200 for S7 during the Facility Visit for failure to transfer S3, S8 and S7 Criminal Background Clearance to the facility.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Direct Service Professional II Felicia Masters.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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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Document Has Been Signed on 04/20/2023 01:15 PM - It Cannot Be Edited


Created By: Melody Brown On 04/20/2023 at 12:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MAC'S HOME #1
FACILITY NUMBER: 331880545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2023
Section Cited
CCR
80065(i)(2)

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80065 Personnel Requirements (i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:(2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by:

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Licensee stated to transfer S3, S7 and S8 criminal background clearance to the facility and associate S3, S7 and S8 to the facility and submit proof to LPA Brown by POC due date.
Licensee stated to submit signed Statement of Understanding on CCR 80065(i)(2) to LPA Brown by POC due date.
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Based on interviews and records review, the Licensee did not comply with the section cited above by not transferring S3, S7 and S8 criminal background clearance to the facility before allowing S3, S7 and S8 to work at the facility which pose potential safety risks to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023


LIC809 (FAS) - (06/04)
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