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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200375
Report Date: 02/14/2025
Date Signed: 02/14/2025 12:17:34 PM

Document Has Been Signed on 02/14/2025 12:17 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:NICOLET II CARE HOMEFACILITY NUMBER:
019200375
ADMINISTRATOR/
DIRECTOR:		JUDY D. SALAZARFACILITY TYPE:
735
ADDRESS:2564 EARLY RIVERS COURTTELEPHONE:
(510) 429-8747
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Judy SalazarTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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On this day at around 8:45 am, LPA Luisa Fontanilla arrived unannounced to conduct annual required inspection and met with staff Josefina Dauz . LPA explained to Dauz the purpose of the visit. The Administrator Judy Salazar arrived at the facility at around 9am.
During the visit, LPA inspected the facility inside and out including but not limited to client rooms, bathrooms, kitchen, dining, garage and backyard. The facility has an approved fire clearance for 4 non ambulatory clients. The facility is a Level 4F home vendorized by the Regional Center of the East Bay (RCEB). One client waiting for pick up was observed at the facility upon arrival. Three clients were in their respective day programs while one is currently in a skilled nursing facility.

Hot water measured at 115.1 Fahrenheit. There was sufficient supply of perishable and non perishable foods. Sufficient supply of hygiene products, warm blankets, towels and sheets in good repair available for client use were observed.

At 9:17 am, LP reviewed P&I money and log with the Administrator. The facility has sufficient amount of surety to cover amount of cash being handled at one time. At 9:57 am, LPA reviewed medications and Medication Administration Record (MAR) with Salazar.

At 10:08 am, LPA reviewed 5 client files and 4 staff files. All staff are fingerprint cleared and associated to the facility. Staff have current first aid and CPR training.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NICOLET II CARE HOME
FACILITY NUMBER: 019200375
VISIT DATE: 02/14/2025
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At around 9am, LPA observed side gate locked with a sliding bolt.

Deficiency is cited per Title 22 California Code of Regulations. Civil penalty of $500 is assessed for today's visit.

Exit interview was conducted with the Administrator. Appeal Rights and a copy of this report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2025 12:17 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/14/2025 at 11:59 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: NICOLET II CARE HOME
FACILITY NUMBER: 019200375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 sliding bolt lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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The Administrator removed bolt during the visit. Deficiency is cleared.
Civil penalty of $500 is assessed for today's visit.
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: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
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