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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440588
Report Date: 05/24/2023
Date Signed: 05/24/2023 08:02:45 PM

Document Has Been Signed on 05/24/2023 08:02 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:BATANGOSO, ANNIEFACILITY TYPE:
735
ADDRESS:2091 DUVAL LANETELEPHONE:
(510) 732-2693
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 4CENSUS: 4DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Annie Batangoso/Administrator and
Lilibeth Lopez/Back-up Administrator		TIME COMPLETED:
08:00 PM
NARRATIVE
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On this day, May 24, 2023, at 4:00 p.m., LPA Delmundo arrived to conduct an annual required inspection. LPA met with Annie Batangoso, administrator, and Lilibeth Lopez, back-up administrator, and informed the reason for visit. LPA also met with other staff, Arleen Pujante.

Facility has an approved LIC808 Mitigation Plan. The facility submitted the LIC9282 Infection Control Plan on 2022,

LPA inspected the facility inside and out including but not limited to living room, dining area, kitchen, bedrooms, bathrooms, garage, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguisher was observed fully charge with tag showed serviced November 28, 2022. Facility has carbon monoxide and smoke detectors that were tested and observed functional. Hot water temperature in the common bathroom was tested, and measured at 109.2 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed earthquake and fire drills last conducted April 16, 2023 and May 17, 2023 respectively. First aid kit inspected and observed complete with manual. Central storage for medications and cleaning supplies were observed lock.

LPA reviewed 5 staff and 4 residents files, and interviewed 2 staff and 1 resident. P&I money checked and reconciled with records. Medications were inspected and compared with records and doctor's orders on file,

At 6:30 p.m., LPA observed 3 residents were over 60 years of age.


.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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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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: 05/24/2023
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LPA received the following updated documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)

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 penalty.

Deficiency and plan and proof of correction were discussed with the administrator.

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: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2023 08:02 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/24/2023 at 07:12 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: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
85068.4 Acceptance and Retention Limitations
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.
-This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 4 residents over 60 years of age which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2023
Plan of Correction
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Administrator to submit an exception request along with supporting documents to retain resident (R1) by 6/07/23.
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: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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