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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200655
Report Date: 01/12/2024
Date Signed: 01/12/2024 01:46:08 PM

Document Has Been Signed on 01/12/2024 01:46 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:ALOHA RESIDENTIAL CARE INCFACILITY NUMBER:
019200655
ADMINISTRATOR:KATELYN SALVADORFACILITY TYPE:
735
ADDRESS:34706 WILLIAMS WAYTELEPHONE:
(510) 972-0900
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
01/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Gina WhiteTIME COMPLETED:
12:00 PM
NARRATIVE
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While at the facility conducting investigation for complaint #15-AS-20240108112058, LPA observed thermostat temperature was at 58 degrees Fahrenheit. Outside temperature was at 50 degrees Fahrenheit. LPA asked Co Administrator Gina White if the heater is working. She states that the heater was found to be not working last Tuesday, 1/9/24. HVAC company was contacted and the technician came on Wednesday, 1/10/24. Gina White states that the technician has ordered necessary parts and will get heater fixed once parts arrive.

Facility does not have any back up heaters for the clients. Clients at the facility were provided with extra blankets.

Deficiency is cited per title 22 California Code of Regulations.

Exit interview is conducted and Appeal Rights was provided to White.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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 01/12/2024 01:46 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 01/12/2024 at 11:48 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: ALOHA RESIDENTIAL CARE INC
FACILITY NUMBER: 019200655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2024
Section Cited
CCR
80088(a)(1)

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Furniture, Fixtures, Equipment, and Supplies
(a) A comfortable temperature for clients shall be maintained at all areas.

(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).
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CoAdministrator will purchase (6) portable heaters and will send LPA proof of purchase by POC date.
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This requirement is not met as evidenced by:
Based on observation, facility did not comply with secton above in not having a working heater. No back up heater was provided.
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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: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
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