<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200880
Report Date: 08/19/2021
Date Signed: 08/19/2021 05:27:54 PM

Document Has Been Signed on 08/19/2021 05:27 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:
(650) 740-5123
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 3DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:VALENCIA-GARCIA, LALLIETIME COMPLETED:
05:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/19/2021 at 2:45 PM, Licensing Program Analysts (LPAs) Leslie Ibo & James Sampair conducted an infection control annual inspection and explained the purpose of the visit with VALENCIA-GARCIA, LALLIE.
Facility is a level 4i. LPAs observed 3 clients during the visit. Facility has a completed mitigation plan. LPAs inspected the facility inside and outside. LPAs observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.



Continued on next page LIC 809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ARIZONA CARE HOME
FACILITY NUMBER: 019200880
VISIT DATE: 08/19/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPAs observed the following:
  • Facility DOES NOT document daily COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility. (technical assistance)
  • Facility living room temperature is 90.6 F
  • LPAs observed paint & insect poison spray where accessible to clients in care - CORRECTED
  • LPAs observed there are animal feces found at the backyard


Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with VALENCIA-GARCIA, LALLIE.

Exit interview conducted and a copy of this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/19/2021 05:27 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/19/2021 at 04:38 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: 08/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1)Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in which LPAs observed paint & insect poison spray where accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2021
Plan of Correction
1
2
3
4
Administrator will need to make sure that disinfectants, cleaning solutions, poisons, firearms and other items that could pose danger to clients are inaccessible to all clients in care. - CLEARED 8/19/20201.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/19/2021 05:27 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/19/2021 at 04:46 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: 08/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPAs observed there are animal feces found at the backyard which posed potential health, safety risk to persons in care.
POC Due Date: 08/27/2021
Plan of Correction
1
2
3
4
Administrator will have cleaning schedule for all staff and trained staff on proper cleaning of the facility including backyard & side yard of the facility. Administrator will need to send proof of training to LPA by POC date.

Type B
Section Cited
CCR
80088(a)(1)
80088 Furniture, Fixtures, Equipment, and Supplies (a) A comfortable temperature for clients shall be maintained at all areas.
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

This requirement is not met as evidenced by:


Deficient Practice Statement
1
2
3
4
Based on observation & interview, the licensee did not comply with the section cited above , LPAs observed the temperature in the living room of the facility is 90.6F, which poses potential health, safety risk to persons in care.
POC Due Date: 08/23/2021
Plan of Correction
1
2
3
4
Facility Administrator will have to install portable air conditioner for the living room area by POC date. Proof of correction need to be submitted to LPA 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/19/2021 05:27 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/19/2021 at 05:02 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: 08/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021


LIC809 (FAS) - (06/04)
Page: 5 of 5