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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441025
Report Date: 08/07/2024
Date Signed: 08/07/2024 01:31:11 PM

Document Has Been Signed on 08/07/2024 01:31 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: 5DATE:
08/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Jackelyn ManaloTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On this day at around 12 noon, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management - incident visit. LPA met with staff Jackelyn Manalo. LPA explained to Manalo the purpose of the visit. The Administrator was informed by Manalo about LPA presence at the facility.

During the visit, LPA obtained Client 1 (C1) and staff records as follows:
  • Physician's Report
  • Appraisal Needs and Services Plan (ANS)
  • Individualized Program Plan (IPP)
  • Individualized Service Plan (ISP)
  • Incident Reports
  • Hospital discharge
  • Doctor's order
  • Identification and Emergency information
  • Staff schedule
  • Personnel Record, first aid/CPR training, DSP on-site orientation for S1 and S2




A copy of this report was provided to Manalo. .
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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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