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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:56:50 PM


Document Has Been Signed on 04/11/2024 12:56 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:COLONIAL ACRES RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200664
ADMINISTRATOR:MAGALLONES, ADELIZA RFACILITY TYPE:
740
ADDRESS:18905 STANDISH AVENUETELEPHONE:
(510) 276-0939
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:20CENSUS: 12DATE:
04/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Adeliza Magallones/Administrator TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit. LPA met with Celeste Olivarez, facility consultant, and Adeliza Magallones, administrator, and informed the reason for visit.

On 3/21/24, LPA issued citations for the following deficiencies with POCs to be submitted by 4/04/24.
Licensee failed to submit the POCs up to this day. Civil penalties are assessed on this day, 4/11/24, and will continue for $100.00/day until POCs are submitted:.
1. Complaint Investigation deficiency section # 1569.269(a)(3). Licensee has not submitted proof that documents were released. nor responded to the reporting party's request and follow-ups.
Civil penalty = $100.00/day x 7 days (from 4/05/24 to 4/11/24)= $700.00
2. Case management deficiency section 87405(a). Magallones who stated she quit as administrator on 12/31/23 and came back 4/03/24; however, licensee failed to submit proof that a full time administrator is hired.
Civil penalty = $100.00/day x 7 days (from 4/05/24 to 4/11/24)= $700.00. In order to satisfy the POC, licensee to submit the following: signed letter indicating Magallones has been re-hired with effective date she took the position; copy of current administrator certificate; LIC500 Personnel Report

POCs and civil penalties were discussed with the Celeste Olivarez and Adeliza Magallones.

Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction form, and copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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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