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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600305
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:22:51 PM

Document Has Been Signed on 04/11/2024 02:22 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: 6DATE:
04/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Katelyn SalvadorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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During a complaint investigation while conducting file reviews, LPAs came across Client 1 (C1) who is diabetic. LPAs interviewed S1 and was informed by S1 that C1 refuses to check own blood sugar. S1 states staff check C1’s blood sugar.

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 was 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
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 04/11/2024 02:22 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 04/11/2024 at 02:13 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: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2024
Section Cited
CCR
80092.8(a)(2)

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80092.8 Diabetes
(a) A licensee of an adult CCF may accept or retain a client who has diabetes if all of the following conditions are met:
(2) The client is mentally and physically capable of administering his/her own medication and performing his/her own glucose testing if applicable, or a licensed professional administers the tests and injections.
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Administrator will seek advice from C1 doctor and Case manager for alternative regrading blood sugar check. Administrator will submit the plan to CCLD by POC date 4/18/2024
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Based on interview and record review, the licensee did not comply with the section cited above:

While conducting file reviews, LPAs came across Client 1 (C1) who is diabetic. LPAs interviewed S1 and was informed by S1 that C1 refuses to check own blood sugar. S1 states staff check C1’s blood sugar.
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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: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


LIC809 (FAS) - (06/04)
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