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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200254
Report Date: 12/29/2023
Date Signed: 01/03/2024 11:13:24 AM

Document Has Been Signed on 01/03/2024 11:13 AM - 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:FAIRFIELDFACILITY NUMBER:
019200254
ADMINISTRATOR:LEEA BURNSFACILITY TYPE:
735
ADDRESS:32724 FAIRFIELD ST.TELEPHONE:
(510) 475-5383
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 4DATE:
12/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Maria Teresa BacaronTIME COMPLETED:
04:50 PM
NARRATIVE
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On this day at a round 12:35 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Maria Teresa Bacaron and informed her about the purpose of the visit.

During the visit, there were 3 clients and 2 staff at the facility, One staff went to pick up another client from the day program. The facility is a Level 4i home vendorized by the Regional Center of the East Bay (RCEB).
The facility has 4 client bedrooms and two bathrooms and has an approved fire clearance for all non ambulatory clients. Room temperature was observed at 71 degrees Fahrenheit. Hot water was measured at 116.2 degrees Fahrenheit.

At 3:52 pm, LPA reviewed P&I money and log. Facility has sufficient surety bond to cover amount of cash being handled at one time. At 4:15, LPA interviewed 2 staff.

During the visit, the following deficiencies were observed:
  • unlocked scissor and screw driver
  • ripped screen door
  • mold on window frames
  • insufficient supply of nonperishable foods


Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Leea Burns.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2023
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 5
Document Has Been Signed on 01/03/2024 11:13 AM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/29/2023 at 03:33 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: FAIRFIELD
FACILITY NUMBER: 019200254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2023

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 a pair of scissors unlocked on the kitchen counter top and screw driver in the small bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Staff locked scissor and screw driver during visit; deficiency cleared.
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: 12/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/03/2024 11:13 AM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/29/2023 at 03:33 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: FAIRFIELD
FACILITY NUMBER: 019200254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)(2)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:  (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (B) Walls and window coverings in client care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled. 

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 mold in window frames which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Administrator will get all windows cleaned/disinfected and submit photo proof to CCL.
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, screen door leading to the activity area is ripped which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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BY POC date, Administrator will get ripped screen door replaced and submit photo proof ot 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: 12/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/03/2024 11:13 AM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/29/2023 at 03:33 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: FAIRFIELD
FACILITY NUMBER: 019200254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 not having sufficient 7-day non perishable food supplies which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator will purchase additional non perishable food supplies and submit proof of purchase to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 12/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5