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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201012
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:47:05 PM

Document Has Been Signed on 02/29/2024 02:47 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:NIDA'S CAREHOME, LLCFACILITY NUMBER:
019201012
ADMINISTRATOR:RAMOS, LEONIDA B.FACILITY TYPE:
735
ADDRESS:34923 OSPREY DRIVETELEPHONE:
(510) 962-0686
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Edith Sarmiento/Nida RamosTIME COMPLETED:
03:00 PM
NARRATIVE
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On this day at around 10:45 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Aida Serrano. LPA explained to Serrano the purpose of the visit. Assistant. Administrator Edith Sarmiento arrived at the facility at around 11:15 am. The Administrator arrived at around 12 noon.

During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining, garage and outside areas. The facility is a Level 4F home vendorized by the Regional Center of the East Bay (RCEB). It has an approved fire clearance for 4 ambulatory and 2 non ambulatory clients. LPA observed a fire extinguisher that appeared full and was last serviced on 7/7/2023. Smoke detectors and carbon monoxide detectors were tested and observed functional. There were sufficient supply of both perishable and non perishable foods. The facility has ample supply of warm blankets, sheets and towels available for use of the clients. First aid kit was inspected and observed complete and updated. Medications were observed locked in a cabinet in the hallway. Hot water in the kitchen and two bathrooms measured at 120 degrees Fahrenheit.

LPA reviewed 5 staff and 5 client files. All staff were observed fingerprint cleared and associated to the facility. Staff have current First Aid and CPR training. The facility's last fire drill was conducted on 2/13/2024 and last earthquake drill was completed on 12/6/2023. P&I money and log were checked. LPA observed the facility does not sufficient amount of surety bond to cover amount of money being handled at one time .
Type B deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview was conducted with the Sarmiento. A copy of this report and Appeal Rights were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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 02/29/2024 02:47 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/29/2024 at 02:32 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: NIDA'S CAREHOME, LLC
FACILITY NUMBER: 019201012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(e)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review the licensee did not comply with the section cited above in not having sufficient amount of bond which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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By POC date, Administrator will provide to CCL an updated proof of bond to cover amount of money being handled at one time.
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: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
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