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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200544
Report Date: 07/24/2020
Date Signed: 07/24/2020 03:44:15 PM

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:AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
019200544
ADMINISTRATOR:ALBERT LEANOFACILITY TYPE:
740
ADDRESS:23652 NEVADA ROADTELEPHONE:
(510) 314-0807
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 5DATE:
07/24/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Manuel "Manny" Jimeno/House Manager.
TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Delmundo called and spoke with Helen Macatangay, licensee. LPA explained that the reason for the call is to inform that a complaint has been received and that LPA will conduct health and safety inspection. Ms. Macatangay indicated she can not come to the facility. LPA and Ms. Macatangay agreed that LPA will call the facility and speak with Manuel "Manny" Jimeno, house manager.

On this same day, July 24, 2020, LPA called and spoke with Mr. Jimeno and informed him of the above. Using telephone's camera, LPA requested Mr. Jimeno to tour LPA to the facility starting from the front door then to the living room, kitchen, dining area, family room, three resident's bedrooms and bathroom. The exit door was observed with auditory signal. There's a bedroom designated for staff use. Four residents were at the facility during inspection, two in the living room and two in the dining area. The facility was observed clean.

No deficiency observed on this day.

Exit interview conducted and copy of this report provided to Ms. Macatangay and Mr. Jimeno via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020
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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