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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600305
Report Date: 04/11/2024
Date Signed: 04/11/2024 01:57:54 PM

Substantiated


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
04/05/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240405135313
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: 6DATE:
04/11/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nicholas A Marcelo, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Facility does not provide modified diet for client with diabetes
Staff are not properly managing the resident's medications and records
Staff are not properly storing refrigerated and frozen foods.
INVESTIGATION FINDINGS:
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On 4/11/24 at 10:00 am, Licensing Program Analyst (LPAs) K. Nguyen and L. Fontanilla arrived unannounced to conduct a complaint investigation in regard to the allegations above. LPAs spoke with Nicholas Marcelo, Administrator (ADM) and explained the purpose of the visit. LPAs observed that there were no clients in the facility. There are four clients attending day program, and two went on an outing.

Allegation: Facility does not have a modified diet for client with diabetes.

During investigation, LPAs conducted interviews with administrator and Staff 1 (S1). S1 stated that the facility provides clients with different types of food such as egg, orange slices. For the day's breakfast, S1 states that peanut butter and jelly sandwich (PB&J) and orange juice were served. LPAs reviewed clients’ files and indicated that Client 1 (C1) has diabetes. Administrator states that they don’t have a modified diet menu for the diabetic client.
Report continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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 6
Control Number 15-AS-20240405135313
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: 04/11/2024
NARRATIVE
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Allegation: Staff are not properly managing the resident's medications and records.

LPAs reviewed Medication Administration Record (MAR) and observed C1, C2, and C3 MAR have missing signatures. LPAs observed C1's MAR missing signature on 4/8 PM, C2 MAR missing signature on 4/9 AM, and C3 MAR missing signature on 4/18, 4/11 AM/PM.

Allegation: Staff are not properly storing refrigerated and frozen foods.

During the visit, LPAs observed uncooked hotdogs left inside the microwave.


Based on LPAs observations, record reviews and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, and listed on LIC 9099D. Failure to submit Proof of Corrections (POC's) by Plan of Correction date may result in civil penalties.


Exit interview conducted with Katelyn Salvador who was authorized by the Administrator to sign the report.

A copy of this report and Appeal Rights were provided to Salvador.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
04/05/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240405135313

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: 6DATE:
04/11/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nicholas A Marcelo, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Facility does not have a functioning kitchen sink.
Facility does not have adequate food supplies.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPAs) K. Nguyen and L. Fontanilla arrived unannounced to conduct a complaint investigation in regard to the allegations above. LPAs spoke with Niko Marcelo, Administrator (ADM) and explained the purpose of the visit. LPA observed that there were no clients in the facility. There are four clients attending day program, and two went on an outing.

Allegation: Facility does not have a functioning kitchen sink.
During the investigation, LPAs observed that facility kitchen sink is functioning.

Allegation: Facility does not have adequate food supplies.
LPAs observed that facility have two refrigerators that have meat, vegetables, bread, milk and eggs. LPAs observed that there are canned foods that are stored in the two cabinets in the garage.

continuation on Lic 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20240405135313
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: 04/11/2024
NARRATIVE
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Based on interviews and records reviewed, the above allegations are unsubstantiated.

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

There is no deficiency noted.

A copy of this report was provided to the Administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20240405135313
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2024
Section Cited
CCR
80076(a)(1)
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80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1)All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. ...

Based on interview and record review, the licensee did not comply with the section cited above
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Administrator will create a month modified diet menu, and train staffs on diabetes management and submit to CCLD by POC date 4/18/24.
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Base on interviewed with S1 and Administrator. Administrator states that they don’t have a modified diet menu for the diabetic client which poses a potential risk to the health and safety of clients under care.

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Type B
04/18/2024
Section Cited
CCR
80065(f)(4)
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80065 Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
(4) Assistance with prescribed medications which are self-administered.
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Administrator will conduct an inservice medication administration training and submit to CCLD by POC date 4/18/24.
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Based on interview and record review, the licensee did not comply with the section cited above:
LPAs reviewed Medication Administration Record (MAR) and observed C1, C2, and C3 MAR have missing signatures. LPAs observed C1's MAR missing signature on 4/8 PM, C2 MAR missing signature on 4/9 AM, and C3 MAR missing signature on 4/18, 4/11 AM/PM.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20240405135313
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2024
Section Cited
CCR
80076(a)(18)
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80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.
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Administrator will conduct an inservice on food safety storage prepraration training and submit to CCLD by POC date 4/18/24.
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Based on LPAs observation, the licensee did not comply with the section cited above:
During the visit, LPAs observed uncooked hotdogs left inside the microwave.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6