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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200026
Report Date: 09/12/2024
Date Signed: 09/12/2024 01:29:28 PM

Document Has Been Signed on 09/12/2024 01:29 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:MARCELO'S CARE HOME #2FACILITY NUMBER:
019200026
ADMINISTRATOR/
DIRECTOR:		KATELYN SALVADORFACILITY TYPE:
735
ADDRESS:33145 FALCON DRIVETELEPHONE:
(510) 487-8097
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY: 6CENSUS: 2DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Katelyn Salvador- Administrator TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 09/12/2024 at 10:00 A.M, Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. The Administrator was informed over the phone about the visit and she arrived at 11:14 A.M. LPAs met with Administrator, Katelyn Salvador and explained the purpose of the visit.

LPA toured the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which 2 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature is maintained at 74 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of hygiene products was available for clients. There is a minimum of one week supply of non-perishables and 2-day perishables food supplies. Smoke detectors and carbon monoxide were tested and observed in operating condition during visit. Fire extinguisher was last serviced on 10/12/2023. Emergency Disaster Drill was last posted on 08/06/2024. First aid kit was observed to be complete.

At 11:45 am, 2 of clients records were reviewed. At 12:15 pm, 3 staff records were reviewed and 3 of 3 are fingerprint cleared and have current first aid training. A sample of 2 client’s medications were reviewed and 2 P&I money and log.

Deficiency is observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiency by POC date may result in additional Civil Penalties.
Exit interview was conducted with Administrator and Appeal Rights and a copy of this report were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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Document Has Been Signed on 09/12/2024 01:29 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/12/2024 at 12:57 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 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 the kitchen sink water measured at 122.9 F and bathroom sink water measured at 121.6 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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The administrator adjusted hot water within range on today's date. The deficiency is 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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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