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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200202
Report Date: 06/14/2023
Date Signed: 06/14/2023 05:21:58 PM

Document Has Been Signed on 06/14/2023 05:21 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:MALAMA HOMEFACILITY NUMBER:
019200202
ADMINISTRATOR:THELMA B. RUIZFACILITY TYPE:
735
ADDRESS:4467 LISA DRIVETELEPHONE:
(510) 475-8052
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 3DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Arlene RuizTIME COMPLETED:
05:30 PM
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On this day at around 1:05 PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct an annual required inspection. LPA met with staff Jimmy Venturero and explained the purpose of visit. Administrators Arlene Ruiz and Thelma Ruiz both arrived at the facility at a later time.

The facility is a Specialized Residential Facility (SRF) vendorized by the Regional Center of the East Bay (RCEB). It has an approved fire clearance for 4 ambulatory clients.

Upon arrival, LPA observed 2 clients and 2 staff on duty. LPA inspected the facility inside and out including but not limited to 3 client bedrooms, 2 bathrooms, kitchen, dining area and backyard. Facility was observed clean and with sufficient lighting. There was no body of water observed. Hot water measured at 106 F in the shared 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 2/13/2023.. Carbon monoxide and smoke detector were tested and observed functional. Medications were observed locked in the office.

Facility has an approved mitigation plan and has a surety bond in the amount of $3,000 which is sufficient to cover amount of money being handled at one time. The last fire drill was conducted on May 15, 2023.

At around 1:05 PM, LPA observed cleaning chemicals under the kitchen sink unlocked and accessible to clients.

At 1:10 PM, LPA reviewed Medication Administration Record (MAR) and medications with Arlene Ruiz. At around 2:05 PM, LPA reviewed staff and client records. At around 3:45 PM, LPA interviewed staff.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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: MALAMA HOME
FACILITY NUMBER: 019200202
VISIT DATE: 06/14/2023
NARRATIVE
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Type A deficiency was cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Ruiz. A copy of this report and Appeal Rights were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2023 05:21 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 06/14/2023 at 05:07 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: MALAMA HOME
FACILITY NUMBER: 019200202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 cleaning chemicals under the sink unlocked and accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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Administrator moved all cleaning chemicals to a locked cabinet during inspection.
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: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
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