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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601366
Report Date: 06/24/2025
Date Signed: 07/03/2025 10:19:17 AM

Document Has Been Signed on 07/03/2025 10:19 AM - 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:FOOTPRINT CARE HOMEFACILITY NUMBER:
015601366
ADMINISTRATOR/
DIRECTOR:		ALMOCERA, SOLEDADFACILITY TYPE:
740
ADDRESS:4647 HANSEN AVENUETELEPHONE:
(510) 797-8719
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
06/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Gene Messick, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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On 06/24/2025 at 8:45 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Direct Care Staff, Gene Messick, and explained the purpose of the visit. Administrator gave authorization for staff to sign the report.

LPA toured facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 3 bedrooms are occupied by the residents and 2 bedroom is occupied by staff. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 07/26/2024.

At 9:27 AM, LPA reviewed 1 staff record. The other 2 staff records were not at the facility for review. At 9:37 AM, LPA reviewed 3 residents records. At 11:00 AM, LPA reviewed a sample of resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 07/02/2025:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
Liability Insurance

Continue to LIC809-C...
Yvonne Flores-LariosTELEPHONE: (510) 286-4201
Patricia ManaloTELEPHONE: (916) 432-7785
DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/03/2025 10:19 AM - It Cannot Be Edited


Created By: Patricia Manalo On 06/24/2025 at 11:05 AM
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: FOOTPRINT CARE HOME
FACILITY NUMBER: 015601366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above by having the side gate locked with a Masterlock and wooden board and the right side with metal chains which poses an immediate health and safety rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Staff removed the Masterlock, wooden board, and metal chains from both side gates during the visit. Deficiency cleared. Civil Penalty of $500 is assessed.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 the water temperature measured at 131.5 degrees Fahrenheit which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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The Administrator agrees to lower the water temperature to be within range 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
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (510) 286-4201
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 432-7785
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2025 10:19 AM - It Cannot Be Edited


Created By: Patricia Manalo On 06/24/2025 at 11:05 AM
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: FOOTPRINT CARE HOME
FACILITY NUMBER: 015601366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 unlocked medication in the kitchen fridge which poses an immediate safety risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Staff removed the medication during the visit. 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (510) 286-4201
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 432-7785
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2025 10:19 AM - It Cannot Be Edited


Created By: Patricia Manalo On 06/24/2025 at 11:05 AM
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: FOOTPRINT CARE HOME
FACILITY NUMBER: 015601366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 not having training for staff which poses a potential health and safety to persons in care.
POC Due Date: 07/08/2025
Plan of Correction
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The Administrator agrees for staff to complete their training and submit proof to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 canned goods in the same storage area as laundry detergent, Ajax cleaning supply, dish soap, Febreeze, etc. which poses a potential health and safety risk to persons in care.
POC Due Date: 07/02/2025
Plan of Correction
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Staff separated the canned goods and cleaning supplies during today's visit. Deficiency cleared.
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
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (510) 286-4201
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 432-7785
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2025 10:19 AM - It Cannot Be Edited


Created By: Patricia Manalo On 06/24/2025 at 11:05 AM
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: FOOTPRINT CARE HOME
FACILITY NUMBER: 015601366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having R2 and R3's files incomplete which poses a potential health and safety risk to persons in care.
POC Due Date: 07/08/2025
Plan of Correction
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The Administrator agrees to complete the residents' file and send proof to CCLD by POC date.
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
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Based on observation and record review, the licensee did not comply with the section cited above by not having a half bed rail order for R1 and R2 which poses a potential health and safety risk to persons in care.
POC Due Date: 07/08/2025
Plan of Correction
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The Administrator agrees to get a doctor's order for R1 and R2's 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
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (510) 286-4201
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 432-7785
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2025 10:19 AM - It Cannot Be Edited


Created By: Patricia Manalo On 06/24/2025 at 11:28 AM
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: FOOTPRINT CARE HOME
FACILITY NUMBER: 015601366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above by not having CPR and/or First Aid certification for all the staff which poses a potential health and safety risk to persons in care.
POC Due Date: 07/02/2025
Plan of Correction
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The Administrator agrees to train all staff in CPR and/or First and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87412(g)
(g) All personnel records shall be maintained at the facility.

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 not having the staff files at the facility which poses a potential safety risk to persons in care.
POC Due Date: 07/08/2025
Plan of Correction
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The Administrator agrees self certify the regulation, store the staff files at the facility, 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
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (510) 286-4201
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 432-7785
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2025


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: FOOTPRINT CARE HOME
FACILITY NUMBER: 015601366
VISIT DATE: 06/24/2025
NARRATIVE
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Continue from LIC809...

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:04 AM, LPA observed unlocked medication in the kitchen fridge.

At 9:10 AM, LPA observed canned food in the same storage area as laundry detergent, Ajax cleaning supply, dish soap, Febreeze, etc.

At 9:11 AM, LPA observed the left side gate locked with a Masterlock and a wooden board and the right side locked with a metal chain. Civil Penalty of $500 is assessed.

At 9:37 AM, staff records were not at the facility for review. Civil Penalty of $250 is assessed.

At 9:37 AM, LPA did not observe any staff training.

At 10:09 AM, record review showed that R2 and R3’s files were incomplete.

At 10:14 AM, observation and record review showed that R1 and R2 with half bed rails and no doctor's order.

At 10:24 AM, LPA observed the hot water temperature measured at 131.5 degrees F.

At 10:58 AM, record review revealed that all staff did not have First Aid and/or CPR Certification.

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 Direct Care Staff. Appeal Rights, Civil Penalty, and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia ManaloTELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC809 (FAS) - (06/04)
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