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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440790
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:18:04 PM

Document Has Been Signed on 02/02/2024 03:18 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 FACILITY #2FACILITY NUMBER:
011440790
ADMINISTRATOR:RAMOS, ZENAIDA CFACILITY TYPE:
735
ADDRESS:4441 ALICE WAYTELEPHONE:
(510) 487-7086
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Flora TimbrezaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Flora Timbreza. LPA explained to Timbreza the purpose of the visit. LPA and Timbreza contacted the Administrator who is unable to come but authorized Timbreza to sign the report.

During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining, garage and outside areas. The facility is a Level 3 home vendorized by the Regional Center of the East Bay (RCEB). LPA observed a fire extinguisher in the kitchen that appeared full and was last serviced on 10/12/2023. Smoke detectors and carbon monoxide detectors were tested and observed functional. There were sufficient supply of both perishable and non perishable foods. The facility has ample supply of warm blankets, sheets and towels available for use of the clients. First aid kit was inspected and observed complete and updated. Medications were observed locked in a cabinet in the family room.

LPA reviewed 5 staff and 5 client files. All staff were observed fingerprint cleared and associated to the facility. Staff have current First Aid and CPR training. P&I money and log were checked. LPA observed the facility has sufficient amount of surety bond to cover amount of money being handled at one time. The facility's last fire drill was conducted on 1/16/2024 and last earthquake drill was completed on 1/21/2024. LPA reviewed medications and Medications Administration Records(MAR) with Timbreza.

At around 11:30 am, LPA observed hot water measured at 126 Fahrenheit.

Facility will submit the following records to LPA by the end of the day: Infection Control Plan, Emergency Disaster Plan, Lic 500, Surety Bond, Disaster Drill, Vehicle Insurance/Registration/License, Lic 400 and Liability insurance.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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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Document Has Been Signed on 02/02/2024 03:18 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/02/2024 at 02:43 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 #2
FACILITY NUMBER: 011440790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 not having hot water temperature between 105-120 Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care. Hot water measured at 126 Fahrenheit.
POC Due Date: 02/02/2024
Plan of Correction
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Administrator adjusted hot water temperature to 115 F during the visit. Deficiency is cleared.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


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 #2
FACILITY NUMBER: 011440790
VISIT DATE: 02/02/2024
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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.

Exit interview was and Appeal Rights was provided with Timbreza.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
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