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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601481
Report Date: 01/30/2025
Date Signed: 01/30/2025 02:22:37 PM

Document Has Been Signed on 01/30/2025 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:COMMON DESTINYFACILITY NUMBER:
015601481
ADMINISTRATOR/
DIRECTOR:		TOM, MARVINFACILITY TYPE:
740
ADDRESS:34209 SYLVESTER DRIVETELEPHONE:
(510) 794-4931
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/30/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Leonora Maquilan, Care Staff TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 01/30/2025 at 1:35 PM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct a Case Management visit. LPAs Care Staff, Leonora Maquilan, and explained the purpose of the visit. The Administrator/ Licensee was unable to come during the visit.

On the annual inspection conducted on 01/07/2025, LPAs observed that R1 was on insulin on a sliding scale. Administrator requested an exception to retain R1 at the facility.

During the visit, LPAs interviewed R1 to verify if resident is able to read and identify the amount of insulin the resident needs based on the reading. R1 stated that they are able to read the number on monitor, however, R1 is unable to determine the correct amount of insulin needed for the particular reading. R1 stated that they are unable to read the numbers on the insulin pen and stated that staff will help with dialing the number and poking the resident.

Exit interview conducted and a copy of this report provided.
Yvonne Flores-LariosTELEPHONE: (510) 286-4201
Patricia ManaloTELEPHONE: (916) 432-7785
DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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