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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200880
Report Date: 03/20/2025
Date Signed: 03/20/2025 04:22:24 PM

Document Has Been Signed on 03/20/2025 04:22 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:
03/20/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Lallie Valencia-GarciaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Luisa Fontanilla arrived on March 20, 2025 and conducted a case management visit as a follow-up to the case management visits made on October 12, 2023, and December 5, 2024. LPA met with Lallie Valencia-Garcia and explained the purpose of the visit.

On October 12, 2023, the Department conducted a case management visit in connection with an incident reported by the facility when a client (C1) was sent out to the hospital.

On December 5, 2024, the Licensee was cited for violating California Code of Regulations (CCR), Title 22 § 85075.4(c) Observation of the Client, California Code of Regulations (CCR), Title 22 § 80092.9(a)(3) Wounds, and California Code of Regulations (CCR), Title 22 § 80091(a)(4) Prohibited Health Condition.

At the time of the case management visit on December 5, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed for serious bodily injury.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Penal Code Section 243 defines serious bodily injury as a serious impairment of physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of function of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement. This is evidenced by the facility not providing observation, care of R1’s skin, and supervision, which resulted in hospitalization, debridement of an unstageable pressure injury of the right hip and cellulitis.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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 2
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: 03/20/2025
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Today, March 20, 2025, the Department will be issuing a civil penalty per Health and Safety Code §1548(f)(1)(A) in the amount of $10,000 for a violation the Department determined resulted in serious bodily injury of C1. However, since an immediate civil penalty of $500 was previously issued on December 5, 2024, the amount of the civil penalty issued today will be $9,500.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Lallie Valencia-Garcia and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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