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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200064
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:01:15 PM

Document Has Been Signed on 10/26/2023 03:01 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:SAN MARTIN RESIDENTIAL CARE #1FACILITY NUMBER:
019200064
ADMINISTRATOR:CONRAD S SABADOFACILITY TYPE:
735
ADDRESS:2879 CHAMIER PLACETELEPHONE:
(510) 745-0668
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY: 6CENSUS: 6DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Conrad SabadoTIME COMPLETED:
03:10 PM
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On this day at around 10:35 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection. LPA was met by staff Felicidad Go. LPA informed Felicidad about the purpose of the visit. The facility is a Level 4C home vendorized by the Regional Center of the East Bay (RCEB). Administrator

Upon arrival, LPA observed 5 clients and one staff. Go states one client is out with family. Three clients were observing doing activities via zoom. The other two clients were in their respective bedrooms. Clients attend day programs every Monday, Wednesday and Friday.

LPA inspected the facility inside and out including but not limited to client bedrooms, bathroom, dining area, kitchen, garage and backyard. Hot water measured at 130 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. Ample supply of sheets, towels, blankets and hygiene products observed. Smoke detectors and carbon monoxide were tested and observed operational. Fire extinguisher appeared full and was last serviced on 10/10/2023.

At 12:20 pm, LPA reviewed P&I money and log. Facility has sufficient amount of surety bond to cover the amount of cash being handled at one time. LPA reviewed Medications Administration Record (MAR) and medications at around. At 12:45 pm, LPA reviewed 5 client files and 3 staff files. At 1:30pm, LPA interviewed 2 clients and one staff.

Last fire drill was conducted on 10/23/2023. Last earthquake drill was done on 9/15/2023.

******continuation on Lic 809C*****
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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 10/26/2023 03:01 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 10/26/2023 at 02:25 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: SAN MARTIN RESIDENTIAL CARE #1
FACILITY NUMBER: 019200064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

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 hot water temperature at 130 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Administrator adjusted hot water to 118 degrees Fahrenheit during the visit. 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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


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: SAN MARTIN RESIDENTIAL CARE #1
FACILITY NUMBER: 019200064
VISIT DATE: 10/26/2023
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The following records were requested to be submitted to CCL by Friday, 10/27/2023:
  • Infection Control Plan
  • Emergency Disaster Plan
  • Surety Bond
  • Lic 400
  • Liability Insurance
  • Resident Roster
  • Lic 500
  • Car registration, insurance and driver licenses


Administrator will also submit request for waiver to use platform beds in all resident rooms.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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