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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200038
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:53:13 PM

Document Has Been Signed on 09/11/2024 03:53 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WALLACE PLACE CARE HOMEFACILITY NUMBER:
019200038
ADMINISTRATOR/
DIRECTOR:		MARISSA RUBIOFACILITY TYPE:
735
ADDRESS:5469 WALLACE PLACETELEPHONE:
(408) 807-2467
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 4DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Marissa Rubio, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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On 09/11/2024 at 11:00 AM, Licensing Program Analysts (LPAs) L. Alexander and P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Direct Support Professionals (DSP), Saniata Melencion and Luisa Barrreras and explained the purpose of the visit. DSPs phoned, Licensee/Administrator, Marissa Rubio to inform. The Licensee/Administrator arrived shortly after. The facility’s fire clearance was approved for six (6) ambulatory. Administrator Certificate #7036240735 expires 11/25/2025.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene supplies were available for clients. There is a minimum of one week supply of non-perishables and 2-day perishables food supply.

Fire extinguisher was last serviced on 07/02/2024. Emergency Disaster Drill was last posted on 02/03/2024. First aid kit was observed to be complete. Fire drill was last conducted on 06/05/2024.

Cont. LIC 809-c...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 09/11/2024 03:53 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 09/11/2024 at 02:30 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: WALLACE PLACE CARE HOME
FACILITY NUMBER: 019200038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 by not having a working carbon monoxide detector which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Administrator will submit photo of installed carbon monoxide to CCLD by POC date.
Type A
Section Cited
CCR
80020(a)
80020 Fire Clearance

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 in by having a latch hooked lock on exit gate. In addition, Client Bedrrom #1 and Staff Bedroom were changed from facility sketch which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Administrator will submit an updated facility sketch for a fire inspection. Administrator will remove the latch lock from exit gate (shown facility sketch) and submit a photo to CCLD by POC date. Immediate civil penalty $500 assessed.
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 09/11/2024 03:53 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 09/11/2024 at 02:30 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: WALLACE PLACE CARE HOME
FACILITY NUMBER: 019200038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 by not having backyard clean with dishwasher, fan, fish tank, furniture, drawers and microwave which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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Administrator will remove items and submit a photo to CCLD by POC date.
Type B
Section Cited
CCR
80088(a)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 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 not having a thermostat which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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The administrator agrees to change the thermostat in the living room and send receipt and photo of new thermostat 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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WALLACE PLACE CARE HOME
FACILITY NUMBER: 019200038
VISIT DATE: 09/11/2024
NARRATIVE
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... Cont. LIC809-C...


At 12:10 P.M, 4 of clients’ records were reviewed. At 1:00pm, 4 staff records were reviewed, and 4 of 4 have current first aid training and associated to the facility. A sample of 1 client’s medications were reviewed.

The following deficiencies were observed (see LIC 809D) and 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.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/18/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility - Reviewed
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
Liability Insurance
LIC 610D Emergency Disaster Plan - Reviewed

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7
Document Has Been Signed on 09/11/2024 03:53 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 09/11/2024 at 03:14 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: WALLACE PLACE CARE HOME
FACILITY NUMBER: 019200038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(c)
85068.4 Acceptance and Retention Limitations
(c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file:

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 by not having updated Physician's Reports for R1 and R3 and letters of support from family and RCEB case manager which poses a potential health and safety risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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Administrator will submit an updated Physician's Report (LIC602A), letters of support from family and RCEB case manager explaining why clients should stay at the ARF to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
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