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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200170
Report Date: 09/27/2024
Date Signed: 09/27/2024 02:40:08 PM

Document Has Been Signed on 09/27/2024 02:40 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MARCELO'S CARE HOME #3FACILITY NUMBER:
019200170
ADMINISTRATOR/
DIRECTOR:		MARCELO, TYLERJAMES AFACILITY TYPE:
735
ADDRESS:3532 MILLER COURTTELEPHONE:
(510) 487-2397
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Tyler Marcelo, Adminstrator TIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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On 09/27/2024 at 10:00 AM, Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Tyler Marcelo and explained the purpose of the visit. The facility’s fire clearance was approved for six ambulatory only.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 6 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/12/2023. Emergency Disaster Drill was last posted on 09/15/2024. First aid kit was observed to be complete. Fire drill was last conducted on 08/15/2024.

At 10:45 am, 6 of clients records were reviewed. At 12:00 PM, 4 staff records were reviewed and 4 of 4 have current first aid training and 4 of 4 associated to the facility. A sample of 2 client’s medications were reviewed and 5 P&I money and log.

Continue LIC 809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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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Document Has Been Signed on 09/27/2024 02:40 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/27/2024 at 01:51 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: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(c)
80025 Bonding (c) The amount of the bond shall be according to the following schedule:
AMOUNT SAFEGUARDED PER MONTH BOND REQUIRED .
$750 or less $1,000
$751 to $1,500 $2,000
$1,501 to $2,500 $3,000
Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the administrator did not comply with the section cited above for not having sufficient Surety Bond coverage for the total P&I facility handles at a time which poses a potential personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Administrator agrees to obtain additional bond coverage, updated LIC 400, and submit proof of items purchased to CCLD by 10/04/2024.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MARCELO'S CARE HOME #3
FACILITY NUMBER: 019200170
VISIT DATE: 09/27/2024
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.. Continue from LIC 809

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator and Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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