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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200170
Report Date: 10/06/2021
Date Signed: 10/06/2021 10:59:45 AM

Document Has Been Signed on 10/06/2021 10:59 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 HOME #3FACILITY NUMBER:
019200170
ADMINISTRATOR:BERNABE, SHIRLEY MFACILITY TYPE:
735
ADDRESS:3532 MILLER COURTTELEPHONE:
(510) 487-2397
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shirley Bernabe, Director/AdministratorTIME COMPLETED:
11:15 AM
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On 10/6/2021 at 9:00AM, Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Shirley Bernabe and explained the purpose of the visit.

Upon entry, LPA's temperatures were checked by Shirley and asked to fill out COVID-19 questionnaire. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed visitors log and facility has a copy of Mitigation Plan and Emergency Disaster Plan on file. LPA observed PPEs, food, and paper supplies are sufficient.


No deficiency cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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