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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200676
Report Date: 03/03/2025
Date Signed: 03/03/2025 06:05:22 PM

Document Has Been Signed on 03/03/2025 06:05 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:H & M HOMES LLCFACILITY NUMBER:
019200676
ADMINISTRATOR/
DIRECTOR:		NERI, OLIVE LYN LFACILITY TYPE:
740
ADDRESS:40726 WOLCOTT DRIVETELEPHONE:
(510) 656-3664
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 6DATE:
03/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Olive Neri, Administrator TIME VISIT/
INSPECTION COMPLETED:
06:20 PM
NARRATIVE
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On 03/03/2025 at 1:55 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Olive Neri, and explained the purpose of the visit. Administrator certificate is current and expires on 09/18/2025. The facility’s fire clearance was approved for all six (6) non-ambulatory.

LPA toured facility with staff inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 124.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pan. There is a minimum of one week supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 02/20/2025. Emergency Disaster Plan was last posted on 12/17/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/28/2025.

At 3:01 PM, LPA reviewed 6 residents records. At 3:37 PM, LPA reviewed 4 staff records and are associated to the facility. At 4:30 PM, LPA reviewed 3 sample of residents' medications.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: H & M HOMES LLC
FACILITY NUMBER: 019200676
VISIT DATE: 03/03/2025
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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 03/10/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 2:18 PM, LPA observed unlocked medication in the fridge.
  • At 2:22 PM, LPA observed a knife unlocked on the counter top dish rack.
  • At 2:28 PM, LPA observed laundry detergent unlocked in the laundry room floor.
  • At 2:36 PM, LPA observed the hot water measured at 124.1 degrees Fahrenheit in the shared bathroom.
  • At 2:39 PM, LPA observed that R5 have a half bed rail and no doctor's order.
  • At 2:45 PM, LPA observed that S2 did not have a First Aid certificate.
  • At 3:30 PM, LPA observed that R1, R3, R5, and R6's file was incomplete.
  • At 4:15 PM, LPA observed that S2 and S3's employee file was incomplete.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 03/03/2025 06:05 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/03/2025 at 05:07 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: H & M HOMES LLC
FACILITY NUMBER: 019200676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having the hot water measured at 124.1 degrees Fahrenheit which poses an immediate health and safety rights risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Administrator agrees to have the water measured within range, self certify send proof to CCLD by POC date.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a knife in the kitchen and laundry detergent in the laundry room unlocked and accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Administrator will lock the items, self certify and send proof to CCLD by POC date.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


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Document Has Been Signed on 03/03/2025 06:05 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/03/2025 at 05:15 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: H & M HOMES LLC
FACILITY NUMBER: 019200676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having unlocked medication found in the fridge accesible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Administrator agrees to lock the medication, self certify, and send proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


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Document Has Been Signed on 03/03/2025 06:05 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/03/2025 at 05:20 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: H & M HOMES LLC
FACILITY NUMBER: 019200676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having S2 and S3's complete files which poses a potential health and safety rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Administrator agrees to obtain the files and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87411(c)(1)
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having First Aid certification for S2 which poses a potential health and safety risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Administrator agrees to have S2 obtain their First Aid certification and send proof to CCLD by POC date.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


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Document Has Been Signed on 03/03/2025 06:05 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/03/2025 at 05:27 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: H & M HOMES LLC
FACILITY NUMBER: 019200676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having a doctor's order for the half bed rail for R5 which poses a potential health and safety risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Administrator agrees to obtain a docotor's order for R5's half bed rail and send proof to CCLD by POC date.
Deficiency Dismissed
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having incomplete resident files for R1, R3, R5, and R6 which poses a potential health and safety risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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2
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Administrator agrees to complete the resident's files and send proof to CCLD by POC date.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


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