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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200170
Report Date: 08/04/2023
Date Signed: 08/04/2023 03:24:35 PM

Document Has Been Signed on 08/04/2023 03:24 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 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: 5DATE:
08/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shirley BernabeTIME COMPLETED:
03:50 PM
NARRATIVE
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On this day at around 10:00 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct annual required inspection. LPA was met by staff Lorna Younger. LPA explained to Younger the purpose of the visit. Administrator Shirley Bernabe arrived at the facility at a later time.

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

Upon arrival, LPA observed 1 client and 3 staff 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 client bedrooms, 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 125.9 degrees F in the kitchen. 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. Medications were observed locked in a cabinet in the hallway.

Facility has an infection control 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.

At 11 am, LPA reviewed 5 client and 5 staff files. LPA interviewed 1 staff and 1 client at 2 pm.

At 2:30 pm, LPA reviewed First Aid kit and observed kit is complete. Last earthquake drill was conducted on
6/19/2023 and last fire drill was conducted on 7/10/2023.

continuation on LIc 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 #3
FACILITY NUMBER: 019200170
VISIT DATE: 08/04/2023
NARRATIVE
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The following deficiencies were observed:
  • hot water in the kitchen measured at 125.9 degrees Fahrenheit
  • side gate which is designated as emergency exit was observed locked
  • S3 was present at the facility but is not fingerprint cleared
  • client rooms were observed without window screens/screen with holes
  • no shaded area for outdoor activity was observed

Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted and Appeal Rights was provided to Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
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Page: 7 of 7
Document Has Been Signed on 08/04/2023 03:24 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/04/2023 at 02:36 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: MARCELO'S CARE HOME #3
FACILITY NUMBER: 019200170

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 side gate emergency exit locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator removed lock during the visit. Deficiency is cleared.
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 that measured 125.9 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator adjusted hot water to 118 degrees Fahrenheit during the visit. Deficiency is cleared.
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: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


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Document Has Been Signed on 08/04/2023 03:24 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/04/2023 at 02:36 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: MARCELO'S CARE HOME #3
FACILITY NUMBER: 019200170

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having S3 present and training at the facility without fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator removed S3 during the visit and will not allow S3 to work until fingerprint 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: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


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Page: 3 of 7
Document Has Been Signed on 08/04/2023 03:24 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/04/2023 at 02:36 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: MARCELO'S CARE HOME #3
FACILITY NUMBER: 019200170

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 not having screen windows in client rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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By POC date, Administrator will have screen windows in good repair installed in all client rooms and submit photo proof to CCL
Type B
Section Cited
CCR
85088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) If the facility operates it own laundry, necessary supplies shall be available and equipment shall be maintained in good repair.

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 not having a working washer and dryer which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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By POC date, Administrator will have a new washer and dryer installed and submit photo proof of receipts and machines to CCL.
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: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


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Page: 4 of 7
Document Has Been Signed on 08/04/2023 03:24 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/04/2023 at 02:36 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: MARCELO'S CARE HOME #3
FACILITY NUMBER: 019200170

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

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 not having a shaded outdoor activity area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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By POC date, Administrator will provide a shaded area outdoor and submit photo proof to CCL by POC date.
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: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


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