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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200026
Report Date: 10/19/2023
Date Signed: 10/19/2023 03:59:10 PM

Document Has Been Signed on 10/19/2023 03:59 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:MARCELO'S CARE HOME #2FACILITY NUMBER:
019200026
ADMINISTRATOR:KATELYN SALVADORFACILITY TYPE:
735
ADDRESS:33145 FALCON DRIVETELEPHONE:
(510) 487-8097
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY: 6CENSUS: 3DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gina WhiteTIME COMPLETED:
04:15 PM
NARRATIVE
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On this day at around 11:30 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA knocked on the door but no one answered. LPA spoke with Administrator Katelyn Salvador and informed her about LPA presence and the purpose of the visit. Administrator states no one is at the facility because all clients at the day program. Katelyn said she will send a staff to assist with the visit since she is attending to an emergency in one of the facilities. At around 12:53pm , staff Lilibeth Lopez arrived to the facility. The facility is a Level 41 home vendorized by the Regional Center of the East Bay (RCEB). The facility has an approved fire clearance for 6 all ambulatory clients. Co Administrator Gina White and staff Carol Pacho Aldueza.

During the visit, LPA inspected the facility inside and out including but not limited to client bedrooms, kitchen, common areas, backyard. The facility is a two storey building with 3 bedrooms and 1 bathroom on the first level and 4 bedrooms and 2 bathrooms on the 2nd level. All client rooms are located on the first level of the facility.

The facility was observed to be clean and odor free. There were multiple fire extinguishers observed that appeared full and were last inspected on 10/12/2023. Smoke detectors and carbon monoxide were tested and observed functional. Medications were observed locked in a cabinet in the kitchen. Chemicals were locked in the hallway. Hot water measured at 110 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. Ample supply of blankets, sheets, towels and hygiene products were observed.
****continuation on Lic 809C****
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MARCELO'S CARE HOME #2
FACILITY NUMBER: 019200026
VISIT DATE: 10/19/2023
NARRATIVE
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At 1:22 pm, LPA checked P&I money and log with Gina White. Facility has surety bond sufficient to cover amount of money being handled at one time.

At 1:27 pm, LPA reviewed medication and Medication Administration Record (MAR).

At 1:45 pm, LPA reviewed 3 client and 5 staff files. At 3:30 pm, LPA interviewed 3 clients and 1 staff.

The following deficiencies were observed:
  • at around 1pm, LPA observed side gate with sliding bolt
  • at around 1:25 pm, LPA observed freezer temperature was at 20 degrees Fahrenheit
  • at around 1:50pm, LPA observed Staff has expired first aid/CPR



Deficiencies cited per Title 22 California Code of Regulations. Refer to the attached Lic 809D.

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2023 03:59 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 10/19/2023 at 03:17 PM
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: MARCELO'S CARE HOME #2
FACILITY NUMBER: 019200026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 in having sidegate exit having a sliding bolt which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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By POC date, Administrator will remove sliding bolt and install self closing latch. Administrator will submit photo proof to CCL.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/19/2023 03:59 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 10/19/2023 at 03:17 PM
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: MARCELO'S CARE HOME #2
FACILITY NUMBER: 019200026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 in having one staff with expired First aid/CPR which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Staff completed FA/CPR training during the visit and submitted proof to LPA. Deficiency is cleared.
Type B
Section Cited
CCR
85076(d)(2)
Food Service
(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 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 in having freezer with temperature at 20 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Administrator has contacted technician to fix refrigerator. If unfixable, facility will replace with a new one immediately. Photo proof will be submitted to CCL.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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