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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440588
Report Date: 06/08/2022
Date Signed: 06/08/2022 07:30:44 PM

Document Has Been Signed on 06/08/2022 07:30 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ARLEEN'S RESIDENTIAL CARE FACILITYFACILITY NUMBER:
011440588
ADMINISTRATOR:ARLENE S PUJANTEFACILITY TYPE:
735
ADDRESS:2091 DUVAL LANETELEPHONE:
(510) 732-2693
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 4CENSUS: 4DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:35 PM
MET WITH:Arlene Pujante/Administrator and
Lilibeth Lopez/Co-Administrator		TIME COMPLETED:
07:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Annie Batangoso, and informed the purpose of visit. LPA called and spoke with Lilibeth Lopez (co-administrator) over the phone who arrived after several minutes. Arlene Pujante, administrator, arrived after Lilibeth Lopez.

Facility has an approved LIC808 Mitigation Plan on file.

LPA toured the facility with Annie Batangoso. LPA inspected the living room, dining area, kitchen, bathrooms. bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer and no touch temperature probe, and Visitor's Log. Visitor's temperature and symptom checks are done at entrance. Residents and staff are screened for COVID-19 symptoms and temperature checked daily. Facility keeps record of proof of vaccination of residents and staff, and antigen test kits are readily available. Supplies of PPEs were checked. and observed adequate for 30 days for 7 staff. Covid-19 signages/posters were observed all throughout the facility. Trash bins with foot pedal operated lids were observed.

At 5:42 pm, LPA observed expired milk in the refrigerator (expiration date: 5/18/2022).

Fire extinguisher checked and observed fully charge with tag showed serviced October 7, 2021. At 5:50 pm, LPA tested the hot water temperature in one of the bathrooms and measured at 110.6 degrees Fahrenheit. First aid kit inspected and observed complete with manual.

.....continued next page
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ARLEEN'S RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 011440588
VISIT DATE: 06/08/2022
NARRATIVE
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On this day, June 8, 2022, LPA obtained copies of the following updated documents:
1. LIC308 Designation of Facility Responsibility
2, LIC400 Affidavit Regarding Client/Resident Cash Resources
3. LIC500 Personnel Report
4. LIC610D Emergency Disaster Plan (9 pages)
5. Proof of Surety Bond coverage

Administrator to submit copy of N95 Fit Testing Record by June 22, 2022.

LPA reminded that new Infection Control Plan should be submitted by June 30. 2022.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/08/2022 07:30 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/08/2022 at 07:09 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ARLEEN'S RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 011440588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(1)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health risk to persons in care. LPA observed expired milk.
POC Due Date: 06/09/2022
Plan of Correction
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Staff discarded the expired item.
Administrator to have all the food supplies checked and conduct in-service training. Proof to be submitted by 6/09/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022


LIC809 (FAS) - (06/04)
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