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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200395
Report Date: 03/06/2024
Date Signed: 03/06/2024 03:00:09 PM

Document Has Been Signed on 03/06/2024 03:00 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:PECO CARE HOMEFACILITY NUMBER:
019200395
ADMINISTRATOR:JEAN B. RODRIGUEZFACILITY TYPE:
735
ADDRESS:34914 PECO STREETTELEPHONE:
(510) 386-4912
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Jean RodriguezTIME COMPLETED:
03:10 PM
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On this day at around 10:55 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Administrator Jean Rodriguez (Administrator Certificate #6000947735 expiration 6/9/2025). LPA explained to the Administrator the purpose of the visit.

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 a fire extinguisher that appeared full and was last serviced on 8/23/23. 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.

LPA reviewed 5 staff and 5 client files. All staff were observed fingerprint cleared and associated to the facility. Staff have current First Aid and CPR training. The facility's last fire drill was conducted on 2/19/24.

P&I money and log were checked. LPA observed the facility did not have sufficient amount of surety bond to cover amount of money being handled at one time.

LPA reviewed medications and Medications Administration Records(MAR) with Rodriguez at around 12:45pm.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Exit interview was and Appeal Rights was provided with Rodriguez.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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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Document Has Been Signed on 03/06/2024 03:00 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/06/2024 at 02:50 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: PECO CARE HOME
FACILITY NUMBER: 019200395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(e)


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 not having sufficient surety bond to cover amount of cash being handled at one time which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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By POC date, the Administrator will send CCL a copy of updated surety bond.
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: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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