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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600305
Report Date: 11/17/2023
Date Signed: 11/17/2023 12:17:17 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
06/22/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220622101438
FACILITY NAME:ARLEEN'S RESIDENTIAL CARE FACILITY #5FACILITY NUMBER:
015600305
ADMINISTRATOR:WARREN FERNANDEZFACILITY TYPE:
735
ADDRESS:27784 ORMOND AVENUETELEPHONE:
(510) 670-2855
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: 5DATE:
11/17/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Nicholas Marcelo, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Licensee is not following resident's agreement for one on one care
Facility operates out of ratio
Facility is not following reporting requirements
Staff do not serve variety of nutritious meals
Staff do not purchase enough food items for residents
Facility does not supply cleaning supplies
Facility is in disrepair
INVESTIGATION FINDINGS:
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On 11/17/2023 at 8:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegations above. LPA met with staff, Roderick Espinoza and informed him the reason for visit. Administrator, Nicholas Marcelo arrived 40 minutes later.

During the course of investigation, LPA interviewed 3 clients and 6 staff. LPA obtained and reviewed documents including physician's report, IPP, ISP, emergency information, blood sugar logs, facility menu, incident report, and staff schedule.

Licensee is not following resident's agreement for one on one care
LPA reviewed C1's IPP and physician's reports and observed that C1 does not require 1:1 care and supervision.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
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-20220622101438
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: 11/17/2023
NARRATIVE
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Facility operates out of ratio
LPA reviewed staff schedule and observed there are two staff schedule when all five clients are present. During LPA's visits on 6/27/2022 and 11/17/2023, LPA observed at least two staff on duty with three to five clients present.

Facility is not following reporting requirements
Interview with staff revealed that staff sometimes write incident reports or administrator would be the one to write and submit incident reports to CCLD. LPA observed an incident report for C6 in 2022. Interview with staff revealed there was no incidents regarding C1 in 2022.

Staff do not serve variety of nutritious meals
LPA observed facility has various foods including eggs, milk, vegetables, fruits, meat, breads, grains, and can goods. LPA observed facility menu has various food groups including protein, carbohydrate, and vegetables. LPA observed C2's physician's report does not indicate C2 is on a special diet.

Staff do not purchase enough food items for residents
Interview with staff and client revealed that facility have run out of food in 2022. However, LPA observed facility has one week of nonperishable and two day perishable food supplies available during visits on 6/27/2022 and 11/17/2023.

Facility does not supply cleaning supplies
LPA observed facility has cleaning supplies and are locked in a cabinet in the garage.

Facility is in disrepair
LPA observed kitchen faucet is loose. However, kitchen faucet is in working condition with hot and cold water. LPA did not observe rust on shower curtain and rod in client's bathroom.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2