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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200676
Report Date: 03/12/2025
Date Signed: 03/12/2025 09:44:06 AM

Document Has Been Signed on 03/12/2025 09:44 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
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:
03/12/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Cimafranca Concepcion, Direct Care Staff TIME VISIT/
INSPECTION COMPLETED:
09:55 AM
NARRATIVE
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On 03/12/2025 at 9:00 AM, Licensing Program Analyst (LPA) P. Manalo arrived to the facility to do a case management visit. LPA met with Direct Care Staff, Cimafranca Concepcion, and explained the purpose of the visit. Administrator gave authorization on the phone for staff to sign the report.

While LPA was at the facility for another visit, LPA observed the following deficiency:

At 9:00 AM, LPA observed two staffs that are not associated to the facility.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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Document Has Been Signed on 03/12/2025 09:44 AM - It Cannot Be Edited


Created By: Patricia Manalo On 03/12/2025 at 09:31 AM
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: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
CCR
87355(e)(2)

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87355(e)(2) Criminal Record Clearance
(e) All individuals subject to a criminal record review.... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified...

This requirement is not met as evidenced by
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The Administrator agrees to have the two staff associated to the facility and send proof to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above in having two staff that are not associated to the facility which poses a potential health and safety risk to persons in care.
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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: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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