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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600131
Report Date: 01/12/2024
Date Signed: 01/12/2024 05:13:43 PM

Document Has Been Signed on 01/12/2024 05:13 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:MV HOMEFACILITY NUMBER:
015600131
ADMINISTRATOR:TERESITA MCLAUGHLINFACILITY TYPE:
735
ADDRESS:32444 NANCY COURTTELEPHONE:
(510) 441-2648
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Teresita McLaughlinTIME COMPLETED:
05:40 PM
NARRATIVE
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On this day at around 2:20 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA met with Administrator Teresita McLaughlin.

During the visit, LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, kitchen, living area, garage and backyard. There were 6 clients and 2 DSP present during the visit. Facility has sufficient supply of perishable and non perishable foods. There was sufficient supply of linen, bath towels, hand towels and warm blankets available for clients. Smoke detectors and carbon monoxide were tested and observed operational. LPA observed a fire extinguisher that appeared full and was last serviced on 12/12/2023. First aid kit was observed complete. There were no bodies of water observed.

LPA reviewed 5 client and 5 staff files. All staff were fingerprint cleared and associated to the facility. And all have current First Aid and CPR training. LPA interviewed 2 staff. LPA reviewed P&I money and log with Administrator.

Hot water measured at 136 degrees Fahrenheit in the kitchen faucet.

Type A deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D)

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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
Document Has Been Signed on 01/12/2024 05:13 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 01/12/2024 at 04:17 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: MV HOME
FACILITY NUMBER: 015600131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water at 136 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Administrator adjusted hot water to 110 degrees Fahrenheit. Deficiency is cleared during the visit.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
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