011441046-2-23-2023-15-AS-ADEO-CPC2XV-20230223164746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 011441046
Report Date: 02/23/2023
Date Signed: 02/23/2023 04:49:03 PM

Document Has Been Signed on 02/23/2023 04:49 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:	ACOB'S HOME CARE		FACILITY NUMBER:	011441046
ADMINISTRATOR:	EDITHA B. ACOB		FACILITY TYPE:	735
ADDRESS:	2453 CABRILLO DRIVE		TELEPHONE:	(510) 780-9421
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	6	CENSUS: 3	DATE:	02/23/2023
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Editha Acob/Licensee-Administrator		TIME COMPLETED:	04:30 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	An Informal Conference was held on this day, February 23, 2023 via video conference. The purpose of this conference was to discuss non-compliance issues. The informal conference process was explained to the licensee-administrator. Licensee-administrator was informed that this Informal Conference is part of the administrative action process, and that further citations will result in a formal Non-Compliance Plan and referral to the Department's Legal Division for possible formal Administrative Action. Present at the meeting were: 1. Licensing Program Manager (LPM) Jeremy Fong 2. Licensing Program Analyst (LPA) Alicia Delmundo 3. Editha Acob/Licensee-Administrator 4. Erin Frey/Regional Center of East Bay Quality Assurance Staff 5. Edmund Arucan/Facility Staff Issues discussed during the meeting: · Fire safety violations · Repeat violations and civil penalties · Non-payment of licensing fee and late fee charge · Reporting requirements · Building and grounds · Submission of proof of corrections · Administrator qualification .......continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ACOB'S HOME CARE	FACILITY NUMBER: 011441046
	VISIT DATE: 02/23/2023

NARRATIVE

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Licensee-administrator to do the following, and submit proof by March 9, 2023:

Hire a new administrator
Pay the licensing fee and late fee charge
Correct the building grounds deficiencies
Correct the other deficiencies
Complete Special Incident Reports for resident (R1)

At the conclusion of this informal conference, licensee-administrator was informed that the facility has to maintain compliance.

Exit interview conducted and copy of this report provided to licensee-administrator via e-mail.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC809 (FAS) - (06/04)

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