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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600305
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:54:09 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2023 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20230824130517
FACILITY NAME:ARLEEN'S RESIDENTIAL CARE FACILITY #5FACILITY NUMBER:
015600305
ADMINISTRATOR:NICHOLAS A MARCELOFACILITY TYPE:
735
ADDRESS:27784 ORMOND AVENUETELEPHONE:
(510) 670-2855
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kayla Harris, Care StaffTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff do not prevent resident from smoking toxic materials in the facility
INVESTIGATION FINDINGS:
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On 8/31/23 at 3:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA spoke with Niko Marcelo, Administrator (ADM) on the phone and explained the purpose of the visit. ADM gave permission for care staff Kayla Harris to sign the report.

During the course of the investigation LPA interviewed the facility administrator (ADM) and inspected the locked medication cabinet where the resident’s cigarettes and lighters are stored. There are 2 residents that smoke (R1 and R2). LPA was unable to interview R1 as he was out of the facility at a doctor’s appointment.


***report continueson LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20230824130517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 FACILITY #5
FACILITY NUMBER: 015600305
VISIT DATE: 08/31/2023
NARRATIVE
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***report continues from LIC9099***

ADM stated that the cigarettes are kept locked, and that staff provide cigarettes to residents on a set schedule throughout the day. Residents receive a cigarette and lighter and go outside to smoke in the designated smoking area. Staff then collect the lighter and lock it back up. ADM also stated that they have never run out of cigarettes for the residents and that he has never seen any residents smoking anything other than cigarettes.

LPA observed the cigarettes and lighters were locked in the medicine cabinet. There was a sufficient supply of cigarettes. During the visit LPA observed R2 receiving his cigarette from staff and going outside to smoke.

Based on LPA interviews and observations we have found that the complaint is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2