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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011441025
Report Date: 02/23/2024
Date Signed: 02/23/2024 05:37:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231213123136
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
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Jackie ManaloTIME COMPLETED:
05:55 PM
ALLEGATION(S):
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Staff did not provide adequate food service
Staff did not provide a safe and comfortable environment for residents
INVESTIGATION FINDINGS:
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On this day at around 3:50 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver findings on the above allegations and met with staff Jackie Manalo. The Administrator was informed over the phone and authorized Jackie to sign the report.

Staff did not provide adequate food service
On 12/21/2023, LPA conducted 10-day investigation. During the visit, LPA observed the facility did not have sufficient supply of perishable foods. Most of the foods observed in the freezer in the kitchen were the microwaveable type. The back up refrigerator in the garage did not have any perishable foods. While at the facility, LPA observed clients were served spaghetti and water for dinner. The spaghetti was observed with very minimal amount of meat. LPA observed some oranges/apples on the countertop, but LPA did not observe staff offering/serving them to the clients. LPA asked S1 what else was being served for dinner. S1 responded, “That’s it.
continuation on Lic 9099C

Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20231213123136
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 #3
FACILITY NUMBER: 011441025
VISIT DATE: 02/23/2024
NARRATIVE
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A review of the facility’s menu indicates that beef stir fry, steamed brown rice, green salad with ranch dressing, fresh fruits, fruit juice and water were listed for dinner.


Staff did not provide a safe and comfortable environment for residents

On 12/21/2023, LPA observed C1 in bed with a chair placed at the foot of the bed supporting C1’s feet. Staff interviewed state the chair is placed at the foot of C1’s bed to support C1’s feet.

Based on LPA observation, the size of C1’s bed is not appropriate for C1’s height.

Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22 are being cited on the attached LIC 9099D.



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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231213123136

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
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Jackie ManaloTIME COMPLETED:
05:55 PM
ALLEGATION(S):
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Staff leave resident in a dirty diaper for extended periods
Staff do not provide activities for the residents
INVESTIGATION FINDINGS:
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On this day, LPA Luisa Fontanilla arrived unannounced to deliver findings on the above allegations and met with staff Jackie Manalo. The Administrator was informed about the visit and authorized Jackie to sign the report

Staff leave resident in a dirty diaper for extended periods

Based on interviews conducted with staff, LPA was informed that C1’s diaper gets checked and changed every two hours or more often, if needed. While at the facility, LPA observed two caregivers changing C1’s diaper. During the visit, LPA did not observe urine smell in C1’s room or any other part of the facility.


continuation on Lic 9099C

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20231213123136
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 #3
FACILITY NUMBER: 011441025
VISIT DATE: 02/23/2024
NARRATIVE
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Staff do not provide activities for the residents

Based on interviews conducted with staff, clients are engaged in different activities when at the facility. Some of the activities that staff conduct with clients are passive exercises, walking around the block, going to the mall and stationary biking. Staff interviewed also state that two clients use their IPADs in addition to the television at the facility.

Based on interviews conducted and LPA observation, the above allegations are unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20231213123136
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 #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 B
02/23/2024
Section Cited
CCR
85076(1)
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85076 Food Service
(d) The licensee shall meet the following food supply and storage requirements:

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
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During the visit, LPA observed sufficient supply of perishable and nonperishable foods available for clients.
This deficiency is cleared during the visit.
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This requirement is not met as evidenced by: Based on observation, the facility did not have sufficient supply of perishable foods which poses a potential risk to health and safety of clients under care.
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Type B
03/08/2024
Section Cited
CCR
80072(a)(2)
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80072(a)(2) Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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C1 is currently in a rehab. Prior to moving back to the facility, Administrator will replace C1's bed to fit C1. C1's current bed is short.
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This requirement is not met as evidenced by:
Based on LPA observation and interview conducted, staff needed to put extra chair at the foot of C1's bed to prevent C1's feet from dangling which poses a potential risk to the health and safety of client under care.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5