<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441025
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:59:24 PM

Document Has Been Signed on 12/10/2024 03:59 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: 4DATE:
12/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Nicholas MarceloTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day at around 3pm, LPAs Luisa Fontanilla and K. Nguyen arrived unannounced to conduct a case management visit related to a death incident and met with Administrator Nicholas Marcelo and Katelyn Salvador. LPAs explained to the Administrator the purpose of the visit.

LPAs interviewed the Administrator and staff 1 (S1).

During the visit, LPAs obtained the following records for Client 1 (C1):
  • skilled nursing discharge
  • Appraisal Needs and Services Plan
  • Emergency Information
  • Admission Agreement
  • Preplacement Appraisal

The written incident and death reports will be sent to CCL within (7) days.

A copy of this report was provided to the Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1