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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200043
Report Date: 06/20/2024
Date Signed: 06/20/2024 12:38:34 PM

Document Has Been Signed on 06/20/2024 12:38 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:ARLEEN'S RESIDENTIAL CARE, INC.FACILITY NUMBER:
019200043
ADMINISTRATOR/
DIRECTOR:		MARCELO, TYLERJAMESFACILITY TYPE:
735
ADDRESS:27749 PENSACOLA WAYTELEPHONE:
(510) 670-2822
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Lilbeth Lopez, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 6/20/24 at 10am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Nelson Galdo. LPA also met with Mercidita Martinez. Lilibeth Lopez, administrator, later arrived.

LPA toured the facility inside out with staff, Nelson Galdo. LPA inspected the kitchen, dining area, living room. bedrooms, bathrooms, garage, front and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Shapes were observed locked and is inaccessible to clients.

Facility has carbon monoxide and smoke detectors that were tested and observed functional. Facility conducts fire and earthquake drills at least every quarter and records showed last conducted April 4, 2024, and February 4, 2024 respectively. Fire extinguisher checked, observed fully charge with tag showed serviced October 27, 2023. Hot water temperature in clients shared bathroom was tested and measured at 113.1 degrees Fahrenheit.

LPA reviews two staff files. 2 out of 2 have TB records on files. LPA reviewed 6 residents files and sample 4 residents medication records.

Report continued on LIC 809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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 06/20/2024 12:38 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 06/20/2024 at 12:10 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: ARLEEN'S RESIDENTIAL CARE, INC.
FACILITY NUMBER: 019200043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having unlock chemical in the metal shed located in the backyard, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Administrator lock the metal shed during inspection. Deficincy cleared
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 by having clients antibacterial cream unlock inside the clients dressers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Administrator lock the antibacterial cream during inspection. Deficincy cleared
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:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ARLEEN'S RESIDENTIAL CARE, INC.
FACILITY NUMBER: 019200043
VISIT DATE: 06/20/2024
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While conducting physical plant inspection, LPA observed the following:

1. at around 10:45 am, LPA observed antibacterial cream inside two client’s dressers.

2. at around 11:00 am, LPA observed unlock chemical in the metal shed in the backyard.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12-month period may result in civil penalty.



Deficiency and plan and proof of correction were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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