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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200154
Report Date: 05/16/2022
Date Signed: 05/16/2022 10:43:08 AM

Document Has Been Signed on 05/16/2022 10:43 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MARCELO'S CARE HOMEFACILITY NUMBER:
019200154
ADMINISTRATOR:LILIBETH LOPEZFACILITY TYPE:
735
ADDRESS:31310 SAN ANDREAS DRIVETELEPHONE:
(510) 487-7066
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH: Leonila David, StaffTIME COMPLETED:
10:57 AM
NARRATIVE
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On 5/16/2022 at 8:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with staff, Leonila David. LPA spoke with administrator, Lilibeth Lopez over the phone and was informed that she is about 1.5-2 hours away. Administrator gave authority to staff, Leonila David to sign the reports.

Upon entry, staff checked LPA's temperature and asked LPA to fill out COVID-19 screening questions. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPA observed cough etiquette, signs & symptoms, and social distancing were posted in the common area. All sinks and bathrooms were equipped with soap and paper towel. Hand washing signs were posted in bathrooms and sinks.

During record review, LPA observed visitors log and temperature log for clients and staff. LPA observed facility has a copy of Mitigation Plan on file. Staff were FIT tested for N95 masks and administrator was able to show pictures of the certificates during inspection. LPA observed PPEs, food supplies, and paper supplies are sufficient.

At 9:10AM, LPA observed unlocked filled paint buckets and propane gas tanks in the backyard. Staff removed filled paint buckets and propane gas tanks from the facility during inspection.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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 05/16/2022 10:43 AM - It Cannot Be Edited


Created By: Grace Luk On 05/16/2022 at 10:20 AM
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: MARCELO'S CARE HOME
FACILITY NUMBER: 019200154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

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 unlocked paint buckets and propane gas tanks in the backyard which poses an immediate health and safety or risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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Staff came by to pick up the filled paint buckets and propane gas tanks and removed them from the facility during inspection.

Deficiency 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022


LIC809 (FAS) - (06/04)
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