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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200154
Report Date: 03/22/2024
Date Signed: 03/22/2024 02:04:18 PM

Document Has Been Signed on 03/22/2024 02:04 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:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Lilibeth LopezTIME COMPLETED:
02:15 PM
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On this day at around 11:20 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct annual required inspection. LPA was met by staff Leonila David. LPA explained to David the purpose of the visit. The Administrator arrived at around 11:45 am.

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 one client in the home. The other 5 clients were in their respective day programs. At around 11:20 am, the 2nd client came back from the day program. 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 were no bodies of water observed. Hot water measured at 115 F in the common bathroom and kitchen. There was sufficient supply of perishable and non perishable foods observed. Fire extinguisher in the kitchen was observed full and was last inspected on 10/12/2023. Carbon monoxide and smoke detector were tested and observed functional. Medications were observed locked in a cabinet in the dining area.

LPA and Administrator reviewed P&I money and log. Facility has a surety bond in the amount of $3,000 which is sufficient to cover amount of money being handled at one time.

At around 11:30am, LPA interviewed 2 clients At around 11:55 am, LPA reviewed 5 client files and 5 staff files. All staff were observed fingerprint cleared and associated to the facility. Staff have current first aid and CPR trainings. continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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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: 03/22/2024
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.At 12:50 pm, LPA reviewed First Aid kit and observed kit is complete. At 12:55 pm, LPA reviewed medications and Medication Administration Record (MAR). At 1:30 pm, LPA interviewed staff.

Last earthquake drill was conducted on 1/19/2024 and last fire drill was conducted on 3/13/2024.

There are no deficiencies noted during the visit.

A copy of this report was provided to the Administrator. .
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
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