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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600305
Report Date: 02/13/2024
Date Signed: 02/13/2024 12:29:52 PM

Document Has Been Signed on 02/13/2024 12:29 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
CCLD Regional Office, 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: 5DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:RODERICK ESPINOZA, CAREGIVERTIME COMPLETED:
01:15 PM
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On 2/13/2024 at 10:00AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct an annual required inspection. LPA met with Caregiver Roderick Espinoza, and explained the purpose of the visit. Administrator Nicholas Marcelo arrived at 11:05AM. Administrator certificate # 6033033735 expiration date 10/21/2024.

LPA toured the facility including but not limited to four (6) bedrooms, two (2) bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water present at this facility. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene were available for clients. Fire extinguisher last serviced on 10/25/2023. Disaster drill last conducted 2/3/2024. First aid kit inspected and complete. Emergency disaster plan posted and dated 1/4/2024.

Four (4) client records were reviewed and found complete. Four (4) staff records reviewed all were found to be complete. All staff were fingerprint cleared and associated to the facility. Staff reviewed had current first aid/ CPR and in good health to perform job functions. P&I reviewed for three (4) clients. P&I was intact and not commingled with facility funds.

Continue on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ARLEEN'S RESIDENTIAL CARE FACILITY #5
FACILITY NUMBER: 015600305
VISIT DATE: 02/13/2024
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continue from LIC809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 02/21/2024:

· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan including infection control plans
· Evidence of Surety Bond

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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