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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440588
Report Date: 06/13/2024
Date Signed: 06/13/2024 07:40:43 PM

Document Has Been Signed on 06/13/2024 07:40 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/
DIRECTOR:		BATANGOSO, ANNIEFACILITY TYPE:
735
ADDRESS:2091 DUVAL LANETELEPHONE:
(510) 732-2693
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 4CENSUS: 4DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Aira Bobares/Administrator TIME VISIT/
INSPECTION COMPLETED:
07:45 PM
NARRATIVE
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On this day, June 13, 2023, at 4:30 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Aira Bobares, administrator, and informed the reason for visit. LPA also met with other staff, Jeane Dionette Aquino and Mildred Gonzales.

Facility submitted the LIC9282 Infection Control Plan on June 10, 2022.

LPA toured the facility inside and out with the administrator. LPA inspected the kitchen, dining area, living room, 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 October 10, 2023. 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 108.9 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed earthquake and fire drills last conducted May 18, 2024 and May 19, 2024 respectively. First aid kit inspected and observed complete with manual. Central storage for medications and cleaning supplies were observed locked.

LPA reviewed 5 staff and 4 residents files, and interviewed 2 staff and 2 residents. P&I money checked and compared with last recorded balance. Medications were inspected and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders on file.

LPA observed the following:
-at 4:54 p.m., uneven ground surface in the backyard.


.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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: 06/13/2024
NARRATIVE
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LPA received the following current/updated documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage
5. Signed letter indicating change of administrator to Aira Bobares along with copies of Bobares' administrator certificate, LIC501 Personnel Record and US issued photo ID.

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: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/13/2024 07:40 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/13/2024 at 07:19 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: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 in uneven ground surface in the backyard.
which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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Administrator to have the ground leveled and submit pictures by 6/2724.
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: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
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