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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200694
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:46:28 PM

Document Has Been Signed on 12/15/2023 02:46 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:H & M HOMES STANDISHFACILITY NUMBER:
019200694
ADMINISTRATOR:OLIVE LOPEZFACILITY TYPE:
740
ADDRESS:18543 STANDISH AVENUETELEPHONE:
(510) 276-2240
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 5DATE:
12/15/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Olive 'Lyn' Lopez-Neri/AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit. LPA rang the doorbell 3x; no answer. LPA called and left message on Olive 'Lyn' Lopez-Neri's (administrator) voice mail and requested for call back. LPA rang the doorbell again and after several minutes. staff, Liwayway Manansala, opened the door. Administrator returned LPA's call, and LPA informed the reason for visit. Administrator arrived at 1:55 p,m.

On 12/08/23, LPA Delmundo conducted an annual required inspection and issued type A citations for the following deficiencies with POCs to be submitted by 12/09/23. Administrator requested extension for submission because 12/09/23 falls on Saturday and the physician is not available. LPA requested POCs be submitted by end of the day of 12/11/23. On 12/11/23, administrator submitted the LIC9098 Proof of Correction form, however, the POCs are missing. LPA responded to the administrator to inform. Administrator submitted the POC and it’s incomplete. LPA responded to administrator the second time, and administrator submitted an incomplete POCs on 12/12/23. Civil penalties are assessed on this day for failure to submit complete POCs.
1. Deficiency section # 87465(e)(2)
Civil penalty = $100.00 x 4 days (12/12/23 to 12/15/23) = $400.00
2. Deficiency section # 87465(a)(4)
Civil penalty = $100.00 x 4 days (12/12/23 to 12/15/23) = $400.00

Administrator provided the POCs to LPA on this day, 12/15/23.

Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction forms, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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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