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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003913
Report Date: 02/08/2023
Date Signed: 02/08/2023 03:19:21 PM


Document Has Been Signed on 02/08/2023 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
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:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:caregiverTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 2/8/23 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required the department's COVID-19 protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was called and arrived to assist.

Infection control plan was unavailable for review. Licensee will submit the plan to LPA for review and document staff training on the plan.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator arrived at the facility. LPA, Administrator, and Infection control Leader completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA and licensee discussed the following: Symptom screening, Fit testing, re-tagging the fire extinguisher, repairing the side gate damaged by storms, retrieve admin cert form other facility .

LPA requested for documents such as LIC 500, Administrator's Certificate, Resident roster, Liability Insurance and completed LIC 308 for designees in the absence of the administrator. Documents to be submitted to LPA via email by due date on, 2/15/23.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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