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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441025
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:07:47 PM

Document Has Been Signed on 05/09/2023 02:07 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:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nicholas MarceloTIME COMPLETED:
02:15 PM
NARRATIVE
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On this day at around 9:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA met with staff Jackelyn Manalo and explained the purpose of visit. Administrator Nicholas Marcelo arrived at around 9:30 am.

During the visit, LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, dining area, garage and backyard. Facility has an approved fire clearance for 2 non ambulatory and 4 ambulatory clients. Facility is a Level 41 home vendorized by the Regional Center of the East Bay (RCEB).

Upon arrival, LPA observed 4 clients in the facility. Manalo states two clients have left for their respective day programs. The other clients either do the zoom classes or attend day programs on scheduled basis.

The facility was observed to be clean and odor free. There was sufficient lighting and no bodies of water were observed. Medications were locked in a cabinet in the hallway. There was sufficient supply of perishable and non perishable foods. Hot water measured at 127.4 degrees Fahrenheit in the common bathroom. Fire extinguishers were observed full and last inspected on 10/4/2022. Passageways were observed free from any obstruction. Carbon monoxide were tested and observed functional. Smoke detectors are interconnected.

At 10:15 am, LPA reviewed First Aid kit and observed it to be complete and updated. At 10:20 am, LPA reviewed P & I money and log with Nicholas. At 11:50 am, LPA reviewed 2 staff and 2 client files. At 12:40 pm, LPA interviewed 2 staff and 2 clients then reviewed medications.

Last fire drill was conducted on January 2023 and last disaster drill was conducted on March 1, 2023.

Type A deficiency was cited per Title 22 California Code of Regulations (Refer to Lic 809D). Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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 05/09/2023 02:07 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 05/09/2023 at 01:52 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: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water temperature measure at 127.4 degree Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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During the visit, Administrator adjusted hot water temperature to 114 degrees and for staff to keep a daily log of hot water temperature.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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