019200880-12-5-2024-15-AS-LFOA-DBNUR9-20241205144823

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 HOME		FACILITY NUMBER:	019200880
ADMINISTRATOR/ DIRECTOR:	VALENCIA-GARCIA, LALLIE		FACILITY TYPE:	735
ADDRESS:	33051 ARIZONA ST		TELEPHONE:	(510) 489-2465
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	12/05/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Lallie Valencia-Garcia		TIME VISIT/ INSPECTION COMPLETED:	03:00 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 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.

Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
Luisa Fontanilla	TELEPHONE: (510) 286-7147
	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

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/06/2024
	Plan of Correction
1 2 3 4	A Non Compliance Conference will be scheduled.

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.

Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
Luisa Fontanilla	TELEPHONE: (510) 286-7147
	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

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/06/2024
	Plan of Correction
1 2 3 4	A Non Compliance Conference (NCC) will be scheduled.

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.

Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
Luisa Fontanilla	TELEPHONE: (510) 286-7147
	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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