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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441025
Report Date: 05/02/2024
Date Signed: 05/02/2024 01:42:08 PM

Document Has Been Signed on 05/02/2024 01:42 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/
DIRECTOR:		NICHOLAS MARCELOFACILITY TYPE:
735
ADDRESS:32302 CREST LANETELEPHONE:
(510) 477-6700
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Katelyn SalvadorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On this day at around 9:40 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA met with staff Zenaida Gustilo and explained the purpose of visit. Katelyn Salvador arrived at a later time. The Administrator was notified about the visit over the phone.

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 5 clients in the facility. Gustilo states one client is in the day program.

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 117 degrees Fahrenheit in the common bathroom. Fire extinguishers were observed full and last inspected on 10/12/2023. Passageways were observed free from any obstruction. Carbon monoxide was tested and observed functional. Smoke detectors are interconnected.

At 10:00 am, LPA reviewed 5 clients and 4 staff files. All staff are fingerprint cleared and associated to the facility. LPA interviewed 2 staff. At 12:20 pm, LPA reviewed P & I money and log with Salvador. The facility has sufficient amount of surety bond to cover the cash being handled at one time. Last fire drill was conducted on April 19, 2024. Based on record review conducted, LPA observed C2 is non ambulatory but is currently living in an ambulatory room.

Type A deficiency was cited per Title 22 California Code of Regulations (Refer to Lic 809D). Exit interview was conducted with Salvador and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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 05/02/2024 01:42 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 05/02/2024 at 12:59 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: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record record review conducted, the licensee did not comply with the section cited above in having C2 live in an ambulatory room. C2 is blind and nonambulatory per Physician's Report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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The Administrator will notify the local fire department about C2 who is nonambulatory and living in an ambulatory room within 24 hours. The Administrator will submit to CCL plan on how to address the issue by POC date.
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: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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