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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441172
Report Date: 04/13/2023
Date Signed: 04/13/2023 03:48:30 PM

Document Has Been Signed on 04/13/2023 03:48 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:BATANGOSO, ANNIEFACILITY TYPE:
735
ADDRESS:2097 DUVAL LANETELEPHONE:
(510) 780-0940
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 4CENSUS: 3DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Annie Batangoso/AdministratorTIME COMPLETED:
03:50 PM
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On this day, April 13, 2023, at 11:45 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Mildred Gozales, and informed the reason for visit. LPA also met with other staff, Gemma Baluyut. Annie Batangoso, administrator, and Lilibeth Lopez, back-up administrator, arrived after several minutes.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining and living areas. Only 1 resident observed during inspection and the other 2 were at day program. Facility has sufficient perishable and non-perishable foods. Fire extinguisher was observed fully charge with tag showed serviced October 4, 2022. Facility has carbon monoxide and smoke detector that were tested and observed functional. Hot water temperature in the common bathroom was tested and measured at 105.1 degrees Fahrenheit.

LPA reviewed 3 residents and 5 staff files, and interviewed 1 resident and 2 staff. Medications were checked and compared against records. Residents' cash resources match with records.

LPA received the following updated documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC400 Affidavit Regarding Client/Resident Cash Resources
3. LIC500 Personnel Report
4. LIC610D Emergency Disaster Plan (9 pages)
5. Proof of Surety Bond coverage

No citation issued during today's inspection.

Exit interview conducted and copy of report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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