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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200880
Report Date: 10/12/2023
Date Signed: 10/12/2023 05:15:32 PM

Document Has Been Signed on 10/12/2023 05:15 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:ARIZONA CARE HOMEFACILITY NUMBER:
019200880
ADMINISTRATOR:VALENCIA-GARCIA, LALLIEFACILITY TYPE:
735
ADDRESS:33051 ARIZONA STTELEPHONE:
(510) 489-2465
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 1DATE:
10/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Lallie Valencia-GarciaTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management visit in connection with an incident reported to CCL. LPA met with Administrator and explained the purpose of the visit.

LPA received an incident report regarding Client 1 (C1) being sent to the hospital due to weakness and decline in condition. A review of C1's hospital discharge paper indicate C1 has Pressure Ulcer, Right Hip, Unstageable (Ulcer covered by slough and/or eschar.

LPA interviewed Administrator who states that C1's father informed staff on 9/9/2023 about redness on C1's right hip. Administrator states staff applied ointment and redness went away. On 9/13/2023, C1 was observed refusing to walk. Day Program driver who picked up C1 had to lift C1 to get to the van because C1 just sat on the ground. Upon return to the facility, C1 was observed weak. On 9/14/2023, C1 was observed refusing to eat, did not want to get up and had a blister on the right hip. C1 was brought to the hospital.

C1 is currently in a skilled nursing facility.

California Code of Regulations, Title 22 is being cited on the attached LIC 809D.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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Document Has Been Signed on 10/12/2023 05:15 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 10/12/2023 at 04:00 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: ARIZONA CARE HOME
FACILITY NUMBER: 019200880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/13/2023
Section Cited
CCR
85075.4(a)

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85075.4 Observation of the Client
(a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.
This requirement is not met as evidenced by:
C1 developed unstageable pressure injury on the right hip while at the facility which poses
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NCC will be scheduled.
Civil penalty of $500 is issued today due to injury
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an immediate risk to the health and safety of clients under care. C1 was hospitalized and currently in a rehab.
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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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
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