336413141-5-3-2023-18-AS-CNWE-CRGQH8-20230503121044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336413141
Report Date: 05/03/2023
Date Signed: 05/03/2023 12:10:53 PM

Document Has Been Signed on 05/03/2023 12:10 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:	SUPPORTING UNLIMITED POSSIBILITIES THE MACK HOUSE		FACILITY NUMBER:	336413141
ADMINISTRATOR:	DEBORAH STANGEL		FACILITY TYPE:	735
ADDRESS:	21800 MACK STREET		TELEPHONE:	(951) 780-3321
CITY:	PERRIS	STATE: CA	ZIP CODE:	92570
CAPACITY: 4		CENSUS: 3	DATE:	05/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Lauren Garrett, Facility Manager Sandra Martinez, Assistant Manager		TIME COMPLETED:	12:15 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 05/03/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by caregiver, Denise Laviera. LPA also met with General Manager, Shanay Waters, Facility Manager, Lauren Garrett, Assistant Manager, Sandra Martinez who were informed of the purpose of visit. At the time of visit there was 5 staff and 1 residents present. LPA toured the facility inside and out with Denise Laviera and Sandra Martinez.

Tour included:

Kitchen; LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen drawer, available only to authorized individuals. Trash cans has tight-fitting lids. Dishwasher is used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge and freezer is large enough to accommodate required perishables and was measured at 4 degrees Fahrenheit and Freezer was measures at 0 degrees Fahrenheit.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 71 degrees Fahrenheit.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Continue on LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUPPORTING UNLIMITED POSSIBILITIES THE MACK HOUSE	FACILITY NUMBER: 336413141
	VISIT DATE: 05/03/2023

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

Continued from LIC809.

Medications; LPA observed medications were labeled and stored in separate drawer inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.

Bathroom; LPA toured three #3 out of #3 facility bathrooms and observed bathrooms to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 107 degrees Fahrenheit.

Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility.

Garage; LPA tour the garage and observed garage to be clean and not cluttered. LPA observed additional refrigerator and freezer.

Laundry; LPA toured the laundry room and observed room to be clean. Washing machine and dryer are all in good repair and sufficient for approved capacity. Cleaning supplies are stored away in the laundry room, and in a locked cabinet in the hallway, inaccessible to clients.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three #3 staff and #3 residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expired on 2/21/2023. Facility Manager, Lauren Garrett stated administrator packet has been sent out for renewal but haven’t heard back from the department.

Interview; Three #3 staff and one #1 resident present were interviewed.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Lauren Garrett.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2