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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003913
Report Date: 03/04/2022
Date Signed: 03/04/2022 03:53:11 PM


Document Has Been Signed on 03/04/2022 03:53 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, 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:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Nelson Jacinto, Administrator TIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Milagros Alvarez, caregiver, and explained purpose of inspection. Nelson Jacinto, Administrator arrived at approximately 2:45 pm. 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: KN95 mask. LPA observed (3) residents sitting in the family room and (3) 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: common areas,(2) private bedrooms, (2) shared bedrooms, (2) bathrooms, dining room, sitting room and kitchen. LPA observed the facility to be clean and in good repair (except small tear in patio screen door screen- technical violation). LPA observed 2+day perishable and 7+day non-perishable food supply. PPE supply for 30+ days on hand. LPA observed various Covid posters throughout. Fire extinguisher last serviced 12/27/2021. LPA observed locked medications and sharps in the kitchen and locked toxins in the laundry room. Discussed and verified vaccination status of residents and staff. Discussed current visitation protocols per Covid-19 precautionary measures. Discussed updating the visitor sign-in page to record date of vaccination, signs/symptoms, and temperature. Discussed posting updated Administrator certificates- Administrator to provide updated copy to the Department. LPA previously requested updated documentation in September 2021.

There are no deficiencies cited during today's inspection. Technical violation issued only. Exit interview with Administrator, 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: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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