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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200309
Report Date: 10/12/2021
Date Signed: 10/12/2021 04:36:08 PM

Document Has Been Signed on 10/12/2021 04:36 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:GLENN VIEWFACILITY NUMBER:
019200309
ADMINISTRATOR:KRISTABELLE ALATASFACILITY TYPE:
735
ADDRESS:38524 GLENVIEW DRIVETELEPHONE:
(510) 894-1971
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 3CENSUS: 4DATE:
10/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Josephine AbellaTIME COMPLETED:
04:45 PM
NARRATIVE
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On 10/12/2021 Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced for another matter. LPA met with Staff Josephine Abella. Administrator Yolanda Alatas was called.

During visit, two Residents R3 and R4 from another licensed facility have been staying at facility since 10/09/2021 temporarily due to emergency evacuation. Resident R1 is at facility and Resident R2 has been staying with family since 10/07/2021, but will return on 10/13/2021. The Oakland Regional CCL office was not notified.

The following deficiency was observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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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Document Has Been Signed on 10/12/2021 04:36 PM - It Cannot Be Edited


Created By: Allison O'Hollaren On 10/12/2021 at 04:24 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: GLENN VIEW
FACILITY NUMBER: 019200309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2021
Section Cited
CCR
80061(a)-(b)

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80061 Reporting Requirements (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. b) Upon the
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By POC date administrator will review regulation and submit a copy of self-certification to CCL by fax or email.
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occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event...This requirement was not met as evidenced by: Based on interview and observation the licensee did not comply with the section cited above. Two Residents R3 and R4 from another licensed facility have been staying at facility since 10/09/2021 temporarily due to emergency evacuation and the Oakland Regional CCL office was not notified which poses a potential health, safety, or personal rights risks to persons in care.
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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:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021


LIC809 (FAS) - (06/04)
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