015600098-8-11-2026-15-AS-KNGN-DWUT44-20260811142320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600098
Report Date: 08/11/2026
Date Signed: 08/11/2026 02:23:31 PM

Document Has Been Signed on 08/11/2026 02:23 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:	R & A RESIDENTIAL CARE FOR THE ELDERLY		FACILITY NUMBER:	015600098
ADMINISTRATOR/ DIRECTOR:	BAUTISTA, ALEJANDRIA		FACILITY TYPE:	740
ADDRESS:	32438 JEAN DRIVE		TELEPHONE:	(510) 441-2457
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY: 6		CENSUS: 6	DATE:	08/11/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Alejandria Bautista, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:35 PM

NARRATIVE

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On 08/11/2026 at 12:45 PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a 1-Year Annual Required inspection. LPA was greeted by care staff, Emilia Malimba. Care staff informed Administrator (AD) Alejandria Bautista (AD). LPA spoke with AD and explained the purpose of the visit. LPA conducted the inspection process; later, ADM arrived.

LPA toured the facility, including but not limited to the front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard.

Smoke Detector and carbon monoxide detector are in operating condition. Fire drills were conducted on 05/15/2026. Fire extinguisher last checked on 08/19/2025. Emergency plan was last posted on 3/10/2026. Facility has current liability insurance from 2026-2027. Hot water measured at 110 degrees F.

LPA reviewed 3 staff records, and 3 out of 3 have TB on file, also associated with the facility. LPA reviewed 6 residents' files.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:

At 1:00 PM, LPA observed unlocked Bigen Speedy Hair Dye, 70% Isopropyl Alcohol, Black Hair Dry Shampoo, and Shimmer Lights shampoo blond and silver in the hallway closet.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with administrator. LIC809D, Appeal Rights, and a copy of this report.

Bennett Fong
Kelly Nguyen
	DATE: 08/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 08/11/2026 02:23 PM - It Cannot Be Edited

Created By: Kelly Nguyen On 08/11/2026 at 02:11 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: R & A RESIDENTIAL CARE FOR THE ELDERLY	FACILITY NUMBER: 015600098
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlcoked Bigen Speedy Hair Dye, 70% Isopropyl Alcohol, Black Hair Dry Shampoo, and Shimmer lights shampoo blond and silver, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/11/2026
	Plan of Correction
1 2 3 4	The Administrator locked the items during the visit. Deficiency cleared. Administrator will conduct an in-service training for staff with topic and attendance to CCLD by POC date: 8/14/26.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

	Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026

LIC809 (FAS) - (06/04)

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