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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441025
Report Date: 02/14/2022
Date Signed: 02/14/2022 01:32:55 PM

Document Has Been Signed on 02/14/2022 01:32 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: 6DATE:
02/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Nicholas Marcelo, AdministratorTIME COMPLETED:
01:45 PM
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On 2/14/2022 starting at 12:50 PM, Licensing Program Analyst (LPA) L. Francisco conducted a Case Management visit while at the facility for another matter. Upon arrival, LPA was greeted by Care Staff, Grace Villareal. Administrator, Nicholas Marcelo later arrived at 1:16 PM.

At 12:55 PM, LPA observed facility's garage is indisrepair. Administrator stated the garage broke the evening of 2/13/2022 while staff was opening the garage. LPA observed an appointment is scheduled for technician to come out and provide facility a quote on 2/15/2022 for repair.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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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