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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441025
Report Date: 02/23/2024
Date Signed: 02/23/2024 05:38:03 PM

Document Has Been Signed on 02/23/2024 05:38 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: 4DATE:
02/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:05 PM
MET WITH:Jackie ManaloTIME COMPLETED:
05:45 PM
NARRATIVE
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During the course of investigation in complaint #15-AS-20231213123136, LPA obtained the following information from interviews conducted and file reviews:
  • C1 is diabetic and needs blood sugar check twice a day. A nurse comes in the morning to check C1's blood sugar but the staff check C1's blood sugar in the afternoon.
  • C1's condition declined from being ambulatory to bedridden during the time of visit on 12/21/2023 without notifying C1's doctor


C1 was sent to the hospital and has been in a skilled nursing facility as of this visit.

Deficiencies are cited per Title 22 California Code of Regulations on the attached Lic 809D.

Exit interview was conducted with Manalo and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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 02/23/2024 05:38 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/23/2024 at 05:12 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 #3
FACILITY NUMBER: 011441025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
CCR
85075.4(a)

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85075.4(a) Observation of the Client
(a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.
This requirement is not met as evidenced by:
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The Administrator will conduct in-service on Section cited and submit proof to CCL by POC date.
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On 12/21/23, LPA observed C1 in bed and unable to move from side to side without staff assistance. C1's Physician's Report indicate C1 is ambulatory but unable to move from side to side. C1 was sent to the hospital and has been in a rehab as of this visit. C1's doctor was not informed about the decline in condition.
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Type B
03/01/2024
Section Cited
CCR80092.8

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80092.8(a)(2) Diabetes
(a) A licensee of an adult CCF may accept or retain a client who has diabetes if all of the following conditions are met:
(2) The client is mentally and physically capable of administering his/her own medication and performing his/her own glucose testing if applicable, or a licensed professional administers the tests and injections.

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Prior to discharge back to the facility, Administrator will evaluate C1's capability of self checking blood sugar and notify LPA.
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This requirement is not met as evidenced by: Based on interview conducted, staff check C1's blood sugar in the afternoon
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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: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024


LIC809 (FAS) - (06/04)
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