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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200880
Report Date: 07/07/2023
Date Signed: 07/07/2023 02:28:49 PM

Document Has Been Signed on 07/07/2023 02:28 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: 3DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lallie Valencia-GarciaTIME COMPLETED:
02:40 PM
NARRATIVE
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On this day at around 9:30 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Administrator Lallie Valencia-Garcia. LPA explained to Administrator the purpose of the visit.

During the visit, LPA inspected the facility inside and out including but not limited to client rooms, bathrooms, dining area, kitchen, garage and backyard. At around 9:50 am, LPA observed hot water measured at 130 degrees in the kitchen faucet. There was sufficient supply of perishable and non perishable food supplies.
Chemicals and medications were observed locked in different cabinets. There was sufficient lighting observed and all passageways were free from obstruction. Facility has multiple dual smoke detectors/carbon monoxide that were tested and observed functional. Fire extinguisher was observed full and last inspected on 7/6/2023.

During the visit, there was one client at the facility with a 1:1 support staff doing activities. The two other clients went to the day program.

At around 10am, LPA reviewed medications and Medication Administration Record (MAR) with Administrator.
At 10:48 am, LPA reviewed P & I money and log. LPA observed facility has sufficient bond to cover amount of money being handled at one time. At 11:05 am, LPA reviewed three client files and four staff files.First aid kit was observed complete. The last fire drill was conducted on June 20, 2023.

At around 1:40 pm, LPA interviewed two staff. LPA attempted to interview 2 of 3 clients. One client was out of the facility.

During the visit, LPA went over with Administrator CARE tool domains verbally since the tool is unavailable.
Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).
Exit interview was conducted and Appeal Rights was provided to Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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 07/07/2023 02:28 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/07/2023 at 01:50 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


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 in having hot water measure at 130 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Administrator adjusted hot water to 118 degrees Fahrenheit during the visit. Deficiency is 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
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