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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200250
Report Date: 04/19/2024
Date Signed: 04/19/2024 03:21:16 PM

Document Has Been Signed on 04/19/2024 03:21 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:MCCLURE CARE HOMEFACILITY NUMBER:
019200250
ADMINISTRATOR/
DIRECTOR:		MUNIZ, SHIELHA CFACILITY TYPE:
735
ADDRESS:2903 MCCLURE STREETTELEPHONE:
(510) 272-0104
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 25CENSUS: 23DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Juliana TaburazaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On this day at 10 am, Licensing Program Analysts (LPAs) Luisa Fontanilla and Kelly Nguyen arrived unannounced to conduct an annual required inspection. LPAs were met by staff Nelson Luat. LPAs explained to Luat the purpose of the visit. Juliana Taburaza was informed about the visit.

During the visits, LPA inspected the facility inside and out including but not limited to client rooms, bathrooms, dining, kitchen and other common areas.There was sufficient supply of perishable and non perishable foods. Multiple fire extinguishers were observed that appeared full and were last serviced on 5/5/2023. Ample supply of hygiene products, towels, sheets and warm blankets were observed. Carbon monoxide were tested and observed functional. First aid kit was observed complete.

LPAs interviewed 3 staff and 2 clients. LPAs reviewed 5 client files and 6 staff files. All staff are fingerprint cleared, associated to the facility and have current First aid and CPR training.

LPAs observed the following deficiencies:
  • Hot water measured at 130 degrees Fahrenheit.
  • Bathroom on the 3rd floor is not functional
  • Ceiling in Room 21 needs repair
  • Wall in Room 3 needs repair
  • Missing Emergency Disaster Plan

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations.

Exit interview conducted was conducted with the Administrator, Appeal Rights and a copy of this report were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/19/2024 03:21 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 04/19/2024 at 02:59 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: MCCLURE CARE HOME
FACILITY NUMBER: 019200250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 at 130 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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The Administrator adjusted hot water to 105 degrees Fahrenheit during the visit. This deficiency is cleared.
Type A
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in not having Emergency Disaster Plan on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
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By POC date, the Administrator will send current Emergency Disaster Plan 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: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/19/2024 03:21 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 04/19/2024 at 02:59 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: MCCLURE CARE HOME
FACILITY NUMBER: 019200250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 one bathroom not functional, wall and ceiling needed repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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The Administrator will get wall/ceiling fixed and will send 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: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
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