<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200267
Report Date: 08/28/2024
Date Signed: 08/28/2024 05:23:35 PM

Document Has Been Signed on 08/28/2024 05:23 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:OAK HOME AT NILES GROVEFACILITY NUMBER:
019200267
ADMINISTRATOR/
DIRECTOR:		MARIA FATIMAR. LACSAMANAFACILITY TYPE:
735
ADDRESS:35543 NILES BLVD.TELEPHONE:
(510) 818-0650
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 6DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Maria Fatima Lacsamana, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/28/2024 at 1:40P.M, Licensing Program Analysts (LPAs) P. Manalo and G. Luk arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Maria Fatima Lacsamana and explained the purpose of the visit. Administrator certificate is current (# 6037469735).

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, and common area. The facility consists of 6 total bedrooms which 6 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in observed during visit. Fire extinguisher was last serviced on 06/06/2024.

At 2:30 P.M, LPA reviewed 3 residents records. At 3:15 P.M, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties.
LPAs is requesting the following documents:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610D Emergency Disaster Plan
Surety Bond
Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 08/28/2024 05:23 PM - It Cannot Be Edited


Created By: Patricia Manalo On 08/28/2024 at 04:26 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: OAK HOME AT NILES GROVE
FACILITY NUMBER: 019200267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having out food supplies in the same storage room with cleaning supplies which poses a potential health, safety risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
1
2
3
4
The facility removed the food item from the storage room on this date. POC cleared on this date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3