019200655-10-13-2023-15-AS-AGOZ-CWKRFY-20231013125956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200655
Report Date: 10/13/2023
Date Signed: 10/13/2023 01:00:04 PM

Document Has Been Signed on 10/13/2023 01:00 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	ALOHA RESIDENTIAL CARE INC		FACILITY NUMBER:	019200655
ADMINISTRATOR:	KATELYN SALVADOR		FACILITY TYPE:	735
ADDRESS:	34706 WILLIAMS WAY		TELEPHONE:	(510) 972-0900
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY: 6		CENSUS: 5	DATE:	10/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Gina White, Backup Administrator		TIME COMPLETED:	01:10 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Luisa Fontanilla and Alona Gomez arrived unannounced to conduct an annual required inspection and met with Administrator Katelyn Salvador and Backup Administrator Gina White. Facility is a Level 4i home vendorized by the Regional Center of the East Bay (RCEB).

There were 3 clients at the facility during inspection. LPAs inspected the facility inside and out including but not limited to client rooms, bathrooms, living room, kitchen, garage and backyard. Facility is a two-level house with 2 client rooms on the first level and 4 client rooms on the second level. There was sufficient supply of perishable and non perishable foods. Hot water measured at 107.1 degrees Fahrenheit. A comfortable temperature of 71 degrees Fahrenheit was observed. Ample supply of linen, sheets and warm blankets were observed available for clients. There was sufficient supply of hygiene products. Hallways and passageways were free of obstruction. There were no bodies of water that would pose a danger to clients observed. Knives, chemicals and medications were locked in separate cabinets. Last fire drill was conducted on 9/04/2023. Fire extinguishers were observed to be full and were last serviced on October 12, 2023. First aid kit was complete. Smoke detectors and Carbon Monoxide were inspected and are in good condition.

At 9:53AM, LPAs observed Screen door on sliding door ripped, outdoor table needs umbrella or an overhead cover, windows need to be cleaned, laundry valves need to be covered, and non-skid matts not present in bathrooms.

At 11:00 AM, LPA reviewed 5 client files and 5 staff files. All staff are fingerprint cleared and have current first aid and CPR training.

At 11:59 AM, LPA reviewed P & I money log. Money was observed intact and log was updated. Facility has surety bond in the amount of $4,000 which is sufficient to cover the amount of money being handled.

Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Gina White and Appeal Rights provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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 10/13/2023 01:00 PM - It Cannot Be Edited

Created By: Alona Gomez On 10/13/2023 at 12:23 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: ALOHA RESIDENTIAL CARE INC	FACILITY NUMBER: 019200655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by Screen door on sliding door being ripped, outdoor table needing umbrella or an overhead cover, windows need to be cleaned, laundry valves need to be covered, and non-skid matts not present in bathrooms which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Administrator agrees to submit photographic proof to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Alona Gomez

LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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