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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 04/19/2024
Date Signed: 04/19/2024 11:14:16 AM


Document Has Been Signed on 04/19/2024 11:14 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: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: 13DATE:
04/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Adeliza Magallones/Administrator TIME COMPLETED:
11:15 AM
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On this day, April 19, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit. LPA met with Adeliza Magallones, administrator, and informed the reason for visit.

On 4/11/24, LPA conducted the first POC visit for the citations issued on 3/21/24 with POCs to be submitted by 4/04/24. Licensee failed to submit the POCs by the due and civil penalties were assessed on 4/11/24. Most of the documents (POC) requested for one of the deficiencies, section # 1569.269(a)(3), were only submitted by the licensee on 4/16/24. Additional civil penalty is assessed for deficiency section # 1569.269(a)(3).

Civil penalty = $100.00/day x 5 days (from 4/12/24 to 4/16/24)= $500.00

Civil penalty was discussed with the Adeliza Magallones.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, 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: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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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