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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200880
Report Date: 08/18/2022
Date Signed: 08/18/2022 05:13:43 PM

Document Has Been Signed on 08/18/2022 05:13 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:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Lallie Valencia-Garcia, AdministratorTIME COMPLETED:
05:25 PM
NARRATIVE
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On 8/18/2022 at 3:05PM, Licensing Program Analysts (LPAs) G. Luk and P. Watson arrived unannounced to conduct an Infection Control Inspection. LPAs met with administrator, Lallie Valencia-Garcia.

Upon entry, staff checked LPA's temperatures and asked to complete visitation log. LPAs observed hand sanitizer at screening station. LPAs toured facility including but not limited to client's bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPAs observed cough etiquette, signs & symptoms, and social distancing posted in common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at bathrooms.

During record review, LPAs observed visitors log. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPEs, food supplies, and paper supplies are sufficient.

At 3:30PM, LPAs observed unlocked laundry softener in hallway closet and unlocked OTC medications in staff room belonging to a staff member.

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

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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 4
Document Has Been Signed on 08/18/2022 05:13 PM - It Cannot Be Edited


Created By: Grace Luk On 08/18/2022 at 04:47 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: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked laundry softener and OTC medications which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/19/2022
Plan of Correction
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Administrator locked up the laundry softener and OTC medications during inspection.

Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022


LIC809 (FAS) - (06/04)
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