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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600467
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:34:55 PM


Document Has Been Signed on 06/19/2024 03:34 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:A-R RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
015600467
ADMINISTRATOR:BAUTISTA, ROMULOFACILITY TYPE:
740
ADDRESS:4733 DARLENE COURTTELEPHONE:
(510) 475-9058
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alejandria Bautista, Assistance Administrator TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Nguyen arrived unannounced to conduct an annual required inspection and met with Assistance Administrator Alejandria Bautista, and later Administrator (AD) Romulo Bautista. AD later left and gave verbal permission to AD assistance to sign the report.

LPA with Assistance Administrator inspected the facility inside and out including but not limited to 4 resident rooms, 2 bathrooms, dining area, garage, and backyard. LPA observed sufficient supply of perishable and nonperishable foods. Hygiene products, towels, sheets and warm blankets were observed. Bathrooms were observed with grab bars and nonskid mat for safety of residents. Fire extinguisher in the kitchen appears full was last inspected on 8/18/23. First aid kit was complete. Last fire drill was conducted on 4/2/24. Facility has an updated disaster plan dated 4/2/2024.

While conducting physical plant inspection, LPA observed the following:

1. at around 11:30 am, LPA observed unlock detergent and bleach unlock in the garage

At 1:00 pm, LPA reviewed 5 resident files and 2 staff files. 2 out of 2 staff have TB on files, LPA reviewed medication and log.

Deficiencies were cited per Title 22 California Code of Regulations.
Exit interview conducted; Appeal Rights provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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 06/19/2024 03:34 PM - It Cannot Be Edited

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: A-R RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 015600467

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlock detergent and bleach unlock in the garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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 Assistance Administrator locked up the chemical during the inspection. Deficiency cleared
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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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