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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600912
Report Date: 08/29/2024
Date Signed: 08/29/2024 02:46:07 PM


Document Has Been Signed on 08/29/2024 02:46 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:MURIEL'S RESIDENTIAL FACILITY IIFACILITY NUMBER:
015600912
ADMINISTRATOR:IRENE M. JENKINSFACILITY TYPE:
740
ADDRESS:4643 HAMPSHIRE WAYTELEPHONE:
(510) 703-8248
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 6DATE:
08/29/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Noel Mario MoralesTIME COMPLETED:
03:00 PM
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On this day at around 2:10 pm, LPA Luisa Fontanilla arrrived unannounced to conducted a Plan of Correction (POC) visit and met with staff Noel Mario Morales. LPA explained to Morales the purpose of the visit. The Administrator was informed over the phone about LPA visit.

On 8/21/2024, a deficiency was issued to the facility for violation of Sec. 87470(a)(2)(A) Infection Control Requirements. The plan of correction (POC) is for the facility to clean and disinfect the bathroom and submit photo proof to CCL by 8/26/2024.

LPA inspected the bathroom and observed it to be clean, disinfected and odor free. Civil penalty of $200 is assessed from 8/27-8/28, 2024.

Exit interview was conducted with Morales and Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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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