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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600131
Report Date: 01/24/2025
Date Signed: 01/24/2025 02:03:08 PM

Document Has Been Signed on 01/24/2025 02:03 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MV HOMEFACILITY NUMBER:
015600131
ADMINISTRATOR/
DIRECTOR:		TERESITA MCLAUGHLINFACILITY TYPE:
735
ADDRESS:32444 NANCY COURTTELEPHONE:
(510) 441-2648
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Teresita Mclaughlin, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 01/24/2025 at 11:25 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Teresita Mclaughlin, and explained the purpose of the visit. Administrator certificate is current. The facility’s fire clearance was approved for capacity of six and two may be non-ambulatory.

LPAs toured the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 69 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 121.4 degree Fahrenheit. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/29/2024. First aid kit was observed to be complete. Earthquake drill was last conducted on 10/28/2024.

At 11:36 AM, 6 of 6 client records were reviewed. At 1:01 PM, 3 staff records were reviewed. All 3 staff have current first aid training and are finger print cleared and associated to the facility. LPAs reviewed client's P&I money with log and there was no discrepancies observed. The facility has sufficient surety bond to cover amount of cash being handled. LPAs reviewed all clients medications. All records were observed to be complete and up to date.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MV HOME
FACILITY NUMBER: 015600131
VISIT DATE: 01/24/2025
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/31/2025:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan
Liability Insurance
Auto Insurance
Auto Registration

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 12:32 PM, during record review, LPA observed that C1 and C5 is non ambulatory. Civil Penalty of $500 is assessed.

At 12:50 PM, LPAs observed the hot water measured at 121.4 degrees Fahrenheit.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2025 02:03 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/24/2025 at 01:36 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: 01/24/2025

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 by having the hot water temperature measured at 121.4 degrees Fahrenheit which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/25/2025
Plan of Correction
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Staff was able to adjust the water temperature to 118 degrees Fahrenheit during the visit. Deficiency cleared.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 by having over capacity in number of clients with non-ambulatory status which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/25/2025
Plan of Correction
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Within 24 hours, the Administrator will notify the local fire department about the non-ambulatory clients and will send Lic 200/sketch to CCL to request for additional nonambulatory fire clearance. Administrator will also schedule C5 for reassessment of ambulatory status.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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