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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200038
Report Date: 10/03/2024
Date Signed: 10/03/2024 11:06:29 AM

Document Has Been Signed on 10/03/2024 11:06 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
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:
10/03/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Marissa Rubio, LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 010/03/2024 at 9:30 AM, Licensing Program Analysts (LPAs) L. Alexander and P. Manalo arrived unannounced to conduct Proof of Correction (POC) visit. LPAs met with Caregiver, Saniata Melencion, and informed the reason for visit. Saniata phoned the Licensee/Administrator, Marissa Rubio to inform. Marissa arrived around shortly after.

On 09/11/2024, LPAs conducted an Annual visit in which deficiencies were cited. The POC due dates was 09/12/24 for Type A deficiencies and 09/25/24 for Type B deficiencies.

Facility has the following deficiencies that was not cleared:
  • 85068.4(c) $100.00 x 8 Days = $800.00

Civil Penalties in the total amount of $800.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing daily civil penalties until deficiencies is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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