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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441172
Report Date: 04/12/2024
Date Signed: 04/12/2024 04:59:27 PM

Document Has Been Signed on 04/12/2024 04:59 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 #4FACILITY NUMBER:
011441172
ADMINISTRATOR/
DIRECTOR:		BATANGOSO, ANNIEFACILITY TYPE:
735
ADDRESS:2097 DUVAL LANETELEPHONE:
(510) 780-0940
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 4CENSUS: 3DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:05 PM
MET WITH:Lilibeth Lopez/Interim Administrator
TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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At 3:05 p.m., on this day, April 12, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Mildred Gonzales. LPA also met with other staff, Gemma Baluyut and Aira Bobares. Lilibeth Lopez, interim administrator, arrived at around 3:35 p.m.

Facility submitted a copy of LIC9282 Infection Control Plan which LPA received on November 9, 2022. Interim administrator submitted on this day, April 12, 2024, an updated LIC9282.

LPA toured the facility inside out with staff, Mildred Gonzales and Gemma Baluyut. LPA inspected the kitchen, dining area, living room. bedrooms, bathrooms, garage, front, side and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has carbon monoxide and smoke detectors that were tested and observed functional. Facility conducts fire and earthquake drills at least every quarter and records showed last conducted April 4, 2024 and February 4, 2024 respectively. Fire extinguisher checked, observed fully charge with tag showed serviced October 27, 2023. Hot water temperature in the ensuite bathroom was tested and measured at 106.1 degrees Fahrenheit.

LPA interviewed 2 staff and 3 residents.


......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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 2
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: 04/12/2024
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Copies of the following documents were also received on this day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

No deficiency observed on this day.

Due to time constraint, LPA has to come back to continue inspection.

Lilebeth Lopez has to leave, and authorized Mildred Gonzales to sign and receive this report.

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

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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