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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441172
Report Date: 04/29/2022
Date Signed: 04/29/2022 06:04:54 PM

Document Has Been Signed on 04/29/2022 06:04 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 #4FACILITY NUMBER:
011441172
ADMINISTRATOR:ARLENE S PUJANTEFACILITY TYPE:
735
ADDRESS:2097 DUVAL LANETELEPHONE:
(510) 780-0940
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 4CENSUS: 3DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Arlene Pujante/AdministratorTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Arlene Pujante, administrator, and informed the purpose of visit.

Facility has LIC808 Mitigation Plan on file.

LPA toured the facility inside out with Arlene Pujante. LPA inspected the living room, dining area, kitchen, bathrooms, bedrooms, garage, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer and no touch temperature probe. Visitor's temperature and symptom checks are done at entry for visitors. Residents and staff are screened for COVID-19 symptoms and temperature checked daily. Facility keeps record of proof of vaccination of residents and staff, and antigen test kits are readily available. Supplies of PPEs were checked. All staff were fit tested for N95 respirator.

Fire extinguisher checked and observed fully charge with tag showed serviced October 7, 2021. First aid kit was observed complete with manual. Hot water temperature in one of the bathrooms was tested and measured at 107.3 degrees Fahrenheit.

LPA observed supplies of disposable surgical masks and disposable gowns not adequate for 30 days for 8 staff. There's only 50 disposable surgical masks and 58 disposable gowns on hand. .


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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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: ARLEEN'S RESIDENTIAL CARE #4
FACILITY NUMBER: 011441172
VISIT DATE: 04/29/2022
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LPA verified and staff stated they do not check visitors for proof of COVID-19 vaccination,

Administrator to submit the following updated documents by May 13, 2022:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan
4. Proof of Surety Bond coverage

No deficiency cited during today's visit.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC809 (FAS) - (06/04)
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