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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441172
Report Date: 04/18/2024
Date Signed: 04/18/2024 05:26:42 PM

Document Has Been Signed on 04/18/2024 05:26 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:
04/18/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Lilibeth Lopez/Interim Administrator
TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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At 3:30 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual inspection that was started on April 12, 2024. LPA met with staff, Mildred Gonzales., Aira Bobares and Gemma Baluyut. Lilibeth Lopez, interim administrator, arrived at around 4:30 p.m.

LPA reviewed 4 staff and 3 residents files. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Residents' P&I were checked and compared with last recorded balance.

LPA observed the following:
-from 4:05 p.m. to 4:40 pm., quantity of residents' (R1, R2, R3) medications received did not match the quantity on labels on the medications; actual quantity received from the pharmacy were less than the quantity on the labels.

Deficiency is cited from Title 22 California Code of Regulation, and listed on 809D.

Deficiency and plan and proof of correction were discussed with the administrator.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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Document Has Been Signed on 04/18/2024 05:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/18/2024 at 05:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ARLEEN'S RESIDENTIAL CARE #4
FACILITY NUMBER: 011441172

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(3)
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in R1, R2 and R3's quantity on medication labels not matching the actual quantity received which posed a potential health and/or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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Corrected.
Administrator obtained the correct labels from the pharmacy while LPA was at the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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