<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441025
Report Date: 12/08/2022
Date Signed: 12/08/2022 01:37:39 PM

Document Has Been Signed on 12/08/2022 01:37 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 #3FACILITY NUMBER:
011441025
ADMINISTRATOR:NICHOLAS MARCELOFACILITY TYPE:
735
ADDRESS:32302 CREST LANETELEPHONE:
(510) 477-6700
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: DATE:
12/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:NICHOLAS MARCELO, Administrator TIME COMPLETED:
01:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/8/2022 at 10:35 AM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a case management visit regarding incident report received on 11/22/2022, about C1 sustained bruise. LPA met with Caregivers S3, staff S2 and S4. The staff called the Administrator Nicholas Marcelo. LPA spoke with Nicholas M, LPA informed Administrator the purpose of the visit. At around 11:35AM, Administrator arrived at the facility.

LPA toured the facility’s inside and outside. During the tour and staff interview, LPA observed the following;
1. Medication cabinet observed to be unlocked which was accessible to clients in care.
2. Cleaning product and pair of scissors was observed to be unlocked and accessible to clients in care
3. Staff did not conduct covid19 screening to LPA upon entering the facility. Technical assistance provided.

During the case management visit, LPA gathered documents such as but not limited to; LIC500, staffing schedule, copy of C1’s physician’s report, C1’s individual program plan (IPP), C1’s individual service plan (ISP). LPA conducted staff and client’s interview. LPA requested for facility staffs’ names with their contact numbers to be sent by 12/9/2022.

Due to insufficient information at this time, LPA will conduct additional interviews and documents reviews. LPA will return to the facility.

Deficiency is cited from Title 22 California Code of Regulations and listed 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/08/2022 01:37 PM - It Cannot Be Edited


Created By: Leslie Ibo On 12/08/2022 at 12:58 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 #3
FACILITY NUMBER: 011441025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2022
Section Cited
CCR
80087(g)

1
2
3
4
5
6
7
80087(g) Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Staff locked the medication cabinet during inspection, pair of scissors was placed on locked cabinet and disinfectant cabinet was locked. Citation was cleared during the visit.
8
9
10
11
12
13
14
Based on observation and interview the licensee did not comply with the section cited above. LPA observed unlocked medication cabinet, pair of scissors and cleaning products that were accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Administrator agreed to retrain staff and submit proof of in-service training to CCL by 12/12/2022.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2