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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003913
Report Date: 09/08/2021
Date Signed: 09/08/2021 02:45:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MACKELLAH HOME IIFACILITY NUMBER:
347003913
ADMINISTRATOR:JACINTO, NELSON S.FACILITY TYPE:
740
ADDRESS:6236 TEMPLETON DRIVETELEPHONE:
(916) 844-7590
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
09/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Arlene Henry, caregiverTIME COMPLETED:
02:45 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) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Arlene Henry, caregiver, and explained purpose of inspection. LPA spoke to Administrator, Nelson, by phone, who was at a related facility and unable to come to this facility during the time of the inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and was requested to do so also upon entering the facility. The following Personal Protective Equipment (PPE) was worn: surgical mask. LPA observed (2) residents sitting in the family room and (4) residents to be in their rooms. There are no residents currently receiving hospice services.

LPA and Administrator toured and observed the facility to ensure the health and safety of residents in care. Areas toured include, but are not limited to: common areas,(2) private bedrooms, (2) shared bedrooms, (2) bathrooms, dining room and kitchen. LPA discussed how beds in shared rooms need to be 6 feet apart or 6 feet apart diagonally, from head to toe orientation. LPA observed 2+day perishable and 7+day non-perishable food supply. PPE supply for 30+ days on hand. In the areas toured, there were no immediate health, safety, or personal rights violations observed. LPA and Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 75* F. Caregiver advised that staff document daily staff temperatures.

LPA requested updated copy of LIC500, LIC610E and liability insurance be faxed to the department by 9/15/2021. Discussed current testing requirements. All staff and residents are currently fully vaccinated.

There are no deficiencies cited during today's inspection.
Exit interview with caregiver who was authorized to sign today's report. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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