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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600305
Report Date: 09/04/2024
Date Signed: 09/04/2024 12:34:21 PM

Document Has Been Signed on 09/04/2024 12:34 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/
DIRECTOR:		NICHOLAS A MARCELOFACILITY TYPE:
735
ADDRESS:27784 ORMOND AVENUETELEPHONE:
(510) 670-2855
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 5DATE:
09/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Johnmerck Martinez, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 9/4/2024 LPA K. Nguyen received a Special Incident Report (SIR) regarding an unwitnessed fall that result a cut on client chin. LPA was greeted by Direct Support Professional, John Martinez. LPA spoke with Administrator, Nicholas Marcelo and explained the purpose of the visit. Nicholas was not able to meet with LPA during the visit. LPA received verbal permission for John to sign the report.

LPA interviewed S1, S2, and reviewed/ obtained discharge summary, and incident care notes from facility. LPA discussed with Nicholas preventative way that can prevent client 1 from falling.

There is no deficiency issue today.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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