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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441025
Report Date: 12/21/2023
Date Signed: 12/21/2023 06:08:11 PM

Document Has Been Signed on 12/21/2023 06:08 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: 5DATE:
12/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:45 PM
MET WITH:Nicholas MarceloTIME COMPLETED:
06:15 PM
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LPA arrived at the facility to conduct 10-day investigation of complaint #15-AS-20231213123136 and met with Administrator Nicholas Marcelo.

During the visit, LPA observed Client 1 (C1) in bed. C1 was covered with blanket and both feet on top of a chair. LPA asked Staff 1 (S1) and Staff 2 (S2) if C1 is able to move from side to side without assistance from staff. Both S1 and S2 state C1 is unable to move from side to side without assistance from two people.

LPA discussed with Administrator that C1 considered bedridden due to inability to independently move from side to side. LPA discussed with Administrator the decline in C1's condition.

Deficiency is cited per Title 22 California Code of Regulations. Civil penalty of $500 is assessed for today.

Exit interview was conducted and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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Document Has Been Signed on 12/21/2023 06:08 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/21/2023 at 05:53 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: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
80010(a)

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80010 Limitations on Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.
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Administrator will:
1. notify the local fire department regarding C1
2. contact primary doctor to seek advice on C1's decline in condition
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This requirement is not met as evidenced by:
Based on interviews and LPA observation, C1 was found to be unable to move from side to side independently and is therefore classified as bedridden. The facility does not have a bedridden fire clearance.
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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: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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