<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 01/10/2023
Date Signed: 01/10/2023 06:17:03 PM


Document Has Been Signed on 01/10/2023 06:17 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:SARAH MAY BALINGITFACILITY TYPE:
740
ADDRESS:18905 STANDISH AVENUETELEPHONE:
(510) 276-0939
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:20CENSUS: 16DATE:
01/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Celeste Olivarez/Facility Consultant
and John Olivarez/Licensee		TIME COMPLETED:
06:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo conducted a case management visit to address the change in administrator.

On November 29, 2022, John Olivarez, licensee, sent to LPA copy of Adeliza Magalonnes's administrator certificate. LPA responded to the licensee on November 30, 2022 requesting to submit by December 2, 2022 a signed letter indicating the effective date Magalonnes took over the position of administrator and a copy of LIC501 Personnel Record. Licensee has not submitted the requested documents as of this day.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction (POC) by plan of correction due dates and any repeat violations within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Celeste Olivarez and licensee.

Exit interview conducted. Appeal Rights, 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: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/10/2023 06:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2023
Section Cited

1
2
3
4
5
6
7
87211 Reporting Requirements
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:
(1) Name and residence and mailing addresses of the new administrator.


1
2
3
4
5
6
7
Licensee to submit the requested documents by 1/17/23.
8
9
10
11
12
13
14
(2) Date he/she assumed his/her position.
(3) Description of his/her background and qualifications, including documentation of required education and administrator certification.

-This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Type B
01/17/2023
Section Cited

1
2
3
4
5
6
7
CONTINUATION:
-Licensee did not comply with the section above for not submitting the requested documents which poses potential personal rights risks to persons in care.
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2