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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200880
Report Date: 12/05/2024
Date Signed: 12/05/2024 02:48:32 PM

Document Has Been Signed on 12/05/2024 02:48 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/
DIRECTOR:		VALENCIA-GARCIA, LALLIEFACILITY TYPE:
735
ADDRESS:33051 ARIZONA STTELEPHONE:
(510) 489-2465
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 3DATE:
12/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Lallie Valencia-GarciaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On this day at around 2pm, LPAs L. Fontanilla and P. Manalo arrived unannounced to issue correct citation related to the case management visit conducted on 10/12/2023 and met with Lallie Valencia-Garcia. LPAs explained to Garcia the purpose of the visit.

Deficiencies were cited per Title 22 California Code of Regulations.

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

A copy of this report was provided to the Administrator.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 12/05/2024 02:48 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/05/2024 at 01:31 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: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
85075.4(c)

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85075.4(c) Observation of the Client (c) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any.
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A Non Compliance Conference will be scheduled.
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This requirement is not met as evidenced by: The facility failed to apprise the client's personal physician
of the red pressure injury when C1 returned to the facility on September 9, 2023.
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Type A
12/06/2024
Section Cited
CCR80092.9(a)(3)

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80092.9(a)(3) Wounds
(a) A licensee of an adult CCF may accept or retain a client who has a serious wound if all of the following conditions are met:
(3) The licensee ensures that a licensed professional in accordance with the physician's instructions provides the wound care
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A Non Compliance Conference (NCC) will be scheduled.
Civil penalty of $500 is being assessed.
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This requirement is not met as evidenced by: The facility failed to ensure hip wound was staged by the physician or licensed professional in which only a licensed skilled professional can care for the wound.
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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: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/05/2024 02:48 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/05/2024 at 02:12 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: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
80091(a)(4)

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80091 Prohibited Health Conditions
(a) In adult CCFs clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained.
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A Non Compliance Conference (NCC) will be scheduled.
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(4) Stage 3 and 4 dermal ulcers
This requirement is not met as evidenced by: C1 was found to have an unstageable pressure injury on the right hip upon admission to the hospital which poses an immediate to the health and safety of client.
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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: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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