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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200655
Report Date: 10/17/2024
Date Signed: 10/17/2024 11:31:15 AM


Document Has Been Signed on 10/17/2024 11:31 AM - 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: 6DATE:
10/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Gina White, Co-Administrator TIME COMPLETED:
11:40 AM
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LPA K. Nguyen arrived unannounced to conduct a Case Management/ Follow up regrading an incident reported to CCLD on 10/8/24. LPA spoke with Co-Administrator Gina White and explained the purpose of the visit. Gina informed Administrator Katelyn Salvador but was not available to attend during the time of the visit.

According to Gina on 10/9/24 a police officer came by the facility to do a follow-up. The police office came and attempted to speak with the staff that witness the incident that happened on 10/8/24. The police office was observing and talking to neighbors for any witnesses of the incident. Police officer left after, and we haven’t heard anything from the police. There was no police report given. Police report have been requested by facility and will submitted to CCLD after the facility obtain the police report.

Gina said C1 is doing fine, and there’s no concerned of any new behavior that develop. LPA attempted to check in with C1, but C1 was sleeping during the time of the visit.

There’s no deficiency issue during today visit.

Exit interview is conducted and a copy of the report is provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
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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