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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200202
Report Date: 05/10/2024
Date Signed: 05/10/2024 02:41:33 PM

Document Has Been Signed on 05/10/2024 02:41 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/
DIRECTOR:		THELMA B. RUIZFACILITY TYPE:
735
ADDRESS:4467 LISA DRIVETELEPHONE:
(510) 475-8052
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 4DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Thelma RuizTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On this day at around 10:10 AM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility unannounced to conduct an annual required inspection. LPA met with staff Charisma Aguilar. LPA explained to Charisma the purpose of visit. Administrator Thelma Ruiz arrived at the facility at around 10:50 AM.

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. 2 out of 4 clients were in the day program. 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 109.5 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 4/30/2024. Carbon monoxide and smoke detectors were tested and observed functional. Medications were observed locked in the office. The last fire drill was conducted on 3/15/2024.

At around 11:00 AM , LPA reviewed 3 staff and 4 client records. All staff are fingerprint cleared and associated to the facility.

At 12:35 PM, LPA reviewed Medication Administration Record (MAR) and medications with Charisma. At
1 PM, LPA reviewed P&I money and log with the Administrator.

Deficiency is cited per Title 22 California Code of Regulations.

Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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 05/10/2024 02:41 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 05/10/2024 at 01:42 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having C4 stay in an ambulatory room which poses an immediate health, safety or personal rights risk to persons in care. C4's 5/3/2023 Physician's Report indicates C4 needs 1 person assist and has a gait belt. 2018, 2019, 2021, 2023 Physician's Reports indicate C4 is non ambulatory.
POC Due Date: 05/13/2024
Plan of Correction
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BY POC date, the Administrator will schedule C4 for a reassessment to determine ambulatory status and will notify CCL about the schedule.
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: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
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