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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200313
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:13:03 PM

Document Has Been Signed on 04/18/2024 02:13 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:ARCYAN CARE HOMEFACILITY NUMBER:
019200313
ADMINISTRATOR/
DIRECTOR:
MARCY DELA CRUZFACILITY TYPE:
735
ADDRESS:172 TAMARACK DRIVETELEPHONE:
(510) 928-2650
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Marcy Dela CruzTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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On this day at around 10:05 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Amanda Grafia. LPA explained to Grafia the purpose of the visit. The Administrator arrived at the facility at a later time.

Upon arrival, LPA observed 2 staff and 4 clients. Grafia states the clients will be going out on an outing in the community.

During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining, garage and outside areas. The facility is a Level 4C home vendorized by the Regional Center of the East Bay (RCEB). LPA observed fire extinguisher that appeared full and was last serviced on 3/12/2024 . Smoke detectors and carbon monoxide detectors were tested and observed functional. There were sufficient supply of both perishable and non perishable foods. The facility has ample supply of warm blankets, sheets and towels available for use of the clients. First aid kit was inspected and observed complete and updated. Medications were observed locked in a cabinet in the family room.

LPA reviewed 4 staff and 4 client files. All staff were observed fingerprint cleared and associated to the facility. Staff have current First Aid and CPR training. P&I money and log were checked. LPA observed the facility has sufficient amount of surety bond to cover amount of money being handled at one time. The facility's last fire drill was conducted on 3/8/2024 and last earthquake drill was completed on 4/6/2024. LPA reviewed medications and Medications Administration Records (MAR) with Grafia.

LPA interviewed 2 staff and 2 clients. LPA reviewed medications and Medication Administration Record with the Administrator.

No deficiencies were noted during the visit. A copy of this report was provided to the Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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