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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600305
Report Date: 02/03/2023
Date Signed: 02/03/2023 01:27:54 PM

Document Has Been Signed on 02/03/2023 01:27 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Nicholas Marcelo, AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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On 2/3/2023 at 12:00 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Administrator, Nicholas Marcelo and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility with Nicholas including but not limited to front entrance, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient two day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily.
Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility has a 30 day supply of PPEs maintained at central location and easily accessible for staff. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. Fire extinguisher was observed serviced. LPA observed facility passages inside and out free of obstruction.

The following deficiency was observed during inspection:
-At approximately 12:30 PM LPA observed volunteer 1 (V1) was not associated to the facility nor fingerprint cleared.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties

Exit interview conducted and a copy of this report provided along with Appeal rights.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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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Document Has Been Signed on 02/03/2023 01:27 PM - It Cannot Be Edited


Created By: Paris Watson On 02/03/2023 at 12:46 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: ARLEEN'S RESIDENTIAL CARE FACILITY #5
FACILITY NUMBER: 015600305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
80019(e)(1)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above by having S1 present without completing a criminal record clearance and associating them to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2023
Plan of Correction
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Administrator will have V1 complete a criminal record clearance and associate them to the facility. Adminstrator will also review the regulations and create a plan regarding volunteer supervison.
Administrator will submit proof to CCL by POC date.
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:Paris Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
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