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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200048
Report Date: 09/06/2024
Date Signed: 09/13/2024 01:01:20 PM

Document Has Been Signed on 09/13/2024 01:01 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:BARBARA RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200048
ADMINISTRATOR/
DIRECTOR:		GEORGE MICHAEL AVILAFACILITY TYPE:
735
ADDRESS:39914 BARBARA STREETTELEPHONE:
(510) 409-9993
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 4DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:George Michael Avila - Administrator TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 09/13/2024 at 10:00 A.M, Licensing Program Analysts (LPAs) Luisa Fontanilla and Patricia Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator George Avila, 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 4 total bedrooms which 2 bedrooms are occupied by the clients and two bedrooms occupied by staff. 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. Hot water in the bathroom faucet measured at 108.1 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 06/17/2024. Emergency Disaster Drill was last posted on 01/03/2024. First aid kit was observed to be complete.

At 10:45 am 4 of 4 clients records were reviewed. At 12:30 pm, 4 staff records were reviewed and 4 of 4 are fingerprint cleared and have current first aid training. A sample of 2 client’s medications were reviewed.

Cont. LIC 809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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 09/13/2024 01:01 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 09/13/2024 at 12:38 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: BARBARA RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

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 having the fence on the right side is leaning inwards, not closing, and is missing a wood plank and the window screen in R1 and R4's room was broken which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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The administrator agrees to fix the fence and repair R1 and R4's window screen and submit proof of photo to CCLD by the 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


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: BARBARA RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200048
VISIT DATE: 09/06/2024
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... Cont. LIC 809..

LPAS requested the following documents to be submitted to CCL by September 20 , 2024:
  • Driver's License
  • Car registration and Proof of Insurance
  • LIC 400
  • LIC 9020

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: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
LIC809 (FAS) - (06/04)
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