015600502-2-27-2025-15-AS-PMAO-DEB33U-20250227165406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600502
Report Date: 02/27/2025
Date Signed: 02/27/2025 04:54:30 PM

Document Has Been Signed on 02/27/2025 04:54 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	MURIEL'S RESIDENTIAL FACILITY		FACILITY NUMBER:	015600502
ADMINISTRATOR/ DIRECTOR:	JENKINS, IRENE M.		FACILITY TYPE:	740
ADDRESS:	38880 FLORENCE WAY		TELEPHONE:	(510) 703-8248
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	02/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:20 AM
MET WITH:	Noel Morales, House Manager		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/27/2025 at 11:20 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Care Staff, Trifina De Leon and explained the purpose of the visit. The Administrator was unable to come today and gave authorization on the phone for staff to sign. The facility’s fire clearance was approved for six (6) non-ambulatory and two (2) hospice waiver. LPA toured facility with staff inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature was measured at 107.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last purchased on 11/27/2024. Emergency Disaster Plan was last posted on 02/02/2024. First aid kit was observed to be complete. Fire Drill was last conducted on 01/03/2025. At 12:34 PM, LPA reviewed 5 residents records. At 1:00 PM, LPA reviewed 5 staff records and associated to the facility. At 2:00 PM, LPA reviewed two sample of resident’s medications. Continue to LIC 809-C...

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 02/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MURIEL'S RESIDENTIAL FACILITY	FACILITY NUMBER: 015600502
	VISIT DATE: 02/27/2025

NARRATIVE

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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 by 03/13/2025:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 11:44 AM, LPA a screw locking the side gate in which the ramp leads in the backyard. Staff stated that they lock it for resident safety. Civil Penalty of $500 is assessed.

At 12:05 PM, LPA observed a wall dividing the staff room in half.

At 12:30 PM, LPA observed that staff uses the bathroom and as a passageway in R1 and R4's room. Staff stated that they are using the bathroom.

At 3:03 PM, LPA observed that R1 and R3 has half bed rail with no doctor's order.

At 4:00 PM, LPA observed that the Administrator certificate expired in 2022.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Staff. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia Manalo	TELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2025 04:54 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MURIEL'S RESIDENTIAL FACILITY	FACILITY NUMBER: 015600502
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a screw locking the side gate where the ramp leads to which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Staff removed the screw during the visit. Deficiency is cleared. Civil penalty of $500 is being assessed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 02/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 02/27/2025 04:54 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MURIEL'S RESIDENTIAL FACILITY	FACILITY NUMBER: 015600502
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

(a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a wall separating the staff room which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/13/2025
	Plan of Correction
1 2 3 4	Staff will communicate with the Licensee/ Administrator about the Plan of Correction and send the plan to CCLD within the week.

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having a doctor's order for R1 and R3 which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/13/2025
	Plan of Correction
1 2 3 4	Staff agrees to speak to the resident's family to obtain doctor's order for the half bed rail and send proof to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 02/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document Has Been Signed on 02/27/2025 04:54 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MURIEL'S RESIDENTIAL FACILITY	FACILITY NUMBER: 015600502
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87307(a)(2)(C)

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having the staff use resident's room as the passageway to the bathroom which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/13/2025
	Plan of Correction
1 2 3 4	Staff agrees to self certify that they have read the regulation and send proof to CCLD by POC date.

Type B

Section Cited

CCR

87405(a)

(a) All facilities shall have a qualified and currently certified administrator... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in having an administrator certificate that expired in 2022 which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/13/2025
	Plan of Correction
1 2 3 4	Administrator agrees to provide documents and send proof of the Administrator certificate pending to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 02/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

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