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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200254
Report Date: 01/09/2025
Date Signed: 01/09/2025 11:32:56 AM

Document Has Been Signed on 01/09/2025 11:32 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:FAIRFIELDFACILITY NUMBER:
019200254
ADMINISTRATOR/
DIRECTOR:		LEEA BURNSFACILITY TYPE:
735
ADDRESS:32724 FAIRFIELD ST.TELEPHONE:
(510) 475-5383
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 3DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Maria Teresa Bacaron, Care StaffTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 01/09/2025 at 8:55 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Direct Care Staff, Maria Teresa Bacaron and explained the purpose of the visit. Administrator gave authorization on the phone for Care Staff to sign the report. The facility’s fire clearance was approved for a capacity of four (4) all may be non-ambulatory and a hospice waiver of one (1).

LPAs toured the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which all 4 bedrooms are occupied by the clients and 2 bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 106.9 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of hygiene products was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply. Centrally stored medication and sharps were locked and inaccessible to clients.

Fire Alarm Inspection was conducted on 06/03/2024. Fire extinguisher was last serviced on 06/25/2024. First aid kit was observed to be complete. Fire drill was last conducted on 06/20/2024. Earthquake drill was last conducted on 11/20/2024.

At 9:23 AM, 3 of clients records were reviewed. At 9:38AM, 3 staff records were reviewed and 4 of 4 have current first aid training and are associated to the facility. LPAs reviewed client's P&I money with log. LPAs reviewed client's medications. All records were observed to be complete and up to date.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FAIRFIELD
FACILITY NUMBER: 019200254
VISIT DATE: 01/09/2025
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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/16/2025:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan
Liability Insurance
Auto Insurance/ Auto Registration
Driver's License

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:15 AM, LPAs observed the floor all throughout the facility not maintained.

At 9:17 AM, LPAs observed the windows and kitchen sink with mold.

At 9:20 AM, LPAs observed cream cheese left on the stove counter.

At 9:30AM, LPAs observed dried leaves and the ground filled with debris in the backyard.


The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Care Staff. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2025 11:32 AM - It Cannot Be Edited


Created By: Patricia Manalo On 01/09/2025 at 11:07 AM
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: 01/09/2025

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 the floor with debris, windows and kitchen sink with mold, and backyard filled with dried leaves and debris on the ground which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator will adress the floor concern and have the other items maintained and send proof to CCLD by POC date.
Type B
Section Cited
CCR
80076(a)(14)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (14) All foods or beverages capable of supporting rapid and progressive growth of microorganisms which can cause food infections or food intoxications shall be stored in covered containers at 45 degrees F (7.2 degrees C) or less.

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 cream cheese left on the stove counter which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Staff removed the item from the stove counter. Deficiency cleared during the visit.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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