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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200202
Report Date: 06/12/2024
Date Signed: 06/12/2024 05:48:16 PM

Document Has Been Signed on 06/12/2024 05:48 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:
06/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Charisma AguilarTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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On this day at around 4pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to obtain records for Client 1 (C1) and to verify C1's ambulatory status. LPA met with Charisma Aguilar. One of the Licensees, Pacifico Ruiz was informed about the visit.

During the visit, 3 staff and 4 clients conducted a fire drill. LPA observed C1 being able to exit the facility without staff physical assistance. Staff provided all clients with verbal instructions and all clients were able to exit on their own.

While at the facility, LPA requested C1's records. LPA was informed that C1's Physician's Reports for the years 2018-2022 have been purged.

Exit interview was conducted with Aguilar.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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