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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200154
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:45:40 PM

Document Has Been Signed on 04/27/2023 02:45 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: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:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lilibeth Lopez, AdministratorTIME COMPLETED:
03:00 PM
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On this day at around 10:30 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct annual required inspection. LPA was met by Administrator Lilibeth Lopez. LPA explained to Administrator purpose of the visit.

The facility is a Level 4H home vendorized by the Regional Center of the East Bay (RCEB). It has an approved fire clearance for 6 ambulatory clients.

Upon arrival, LPA observed 2 clients in the home. The other 4 clients were at their respective day programs. LPA inspected the facility inside and out including but not limited to 4 client bedrooms, 2 bathrooms, kitchen, dining area, garage and backyard. Facility was observed clean and odor free. There was sufficient lighting. There was no body of water observed. Hot water measured at 111 F in the common bathroom. There was sufficient supply of perishable and non perishable foods observed. Fire extinguisher in the kitchen was observed full that was last inspected on 10/4/2022. Carbon monoxide and smoke detector were tested and observed functional. Medications were observed locked in a cabinet in the dining area.

Facility has an approved mitigation plan. Facility has a surety bond in the amount of $3,000 which is sufficient to cover amount of money being handled at one time.

****continuation on Lic 809C***
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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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: MARCELO'S CARE HOME
FACILITY NUMBER: 019200154
VISIT DATE: 04/27/2023
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At 11:30 am, LPA reviewed Medication Administration Record (MAR) and medications for Client 1 and Client 2. At 12 noon, LPA reviewed P & I money with Administrator. At 12:45 pm, LPA reviewed 2 client files and 2 staff files and interviewed 2 clients and 2 staff.

At 2:00 pm, LPA reviewed First Aid kit and observed kit is complete. Last earthquake drill was conducted on 4/13/2023 and last fire drill was conducted on 2/27/2023.
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The following records were obtained during the visit:

1. LIC308 Designation of Facility Responsibility
2. LIC400 Affidavit Regarding Client/Resident Cash Resources
3. LIC500 Personnel Report
4. LIC610D Emergency Disaster Plan (9 pages)
5. Proof of Surety Bond coverage
6. Vehicle Registration, Insurance and Driver's License


There are no deficiencies noted during the visit. A copy of this report was provided to Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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