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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201012
Report Date: 01/30/2025
Date Signed: 01/30/2025 12:26:56 PM

Document Has Been Signed on 01/30/2025 12:26 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:NIDA'S CAREHOME, LLCFACILITY NUMBER:
019201012
ADMINISTRATOR/
DIRECTOR:		RAMOS, LEONIDA B.FACILITY TYPE:
735
ADDRESS:34923 OSPREY DRIVETELEPHONE:
(510) 962-0686
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Leonida Ramos, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 01/30/2025 at 9:10 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Direct Care Staff, Florita Bernardo, who phoned the Administrator and explained the purpose of the visit. Administrator came shortly after. Administrator certificate is current. The facility’s fire clearance was approved for all four ambulatory and two non-ambulatory.

LPAs toured the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 116.4 degree Fahrenheit. The supply of hygiene products was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/09/2024. First aid kit was observed to be complete. Earthquake Drill was last conducted on 12/10/2024.

At 9:25 AM, 5 of 5 clients records were reviewed. At 9:49 AM, 4 staff records were reviewed. All staff are associated to the facility. LPAs reviewed client's P&I money with log and there was no discrepancies observed. LPAs reviewed all of client's medications.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NIDA'S CAREHOME, LLC
FACILITY NUMBER: 019201012
VISIT DATE: 01/30/2025
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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/06/2025:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan
Auto Insurance
Auto Registration

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:30 AM, LPAs observed a rat in the kitchen countertop.

At 9:35 AM, LPAs observed an exercising machine, washer, and dryer in the garage.

At 9:40 AM, LPAs were informed by Direct Care Staff that C4 sleeps at staff's room at night.

At 9:45 AM, LPAs observed unlocked cough medicine in the kitchen

At 11:15 AM, LPAs observed that S4 does not have an updated First Aid and CPR certification.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview was conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 01/30/2025 12:26 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/30/2025 at 11:42 AM
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: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in having a rat in the kitchen countertop and the garage having a strong odor which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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3
4
The licensee will 1) contact pest control immediately to conduct inspection of the whole facility for any pests and 2) clean the facility and ensure it is clean and odor free . LPAs will come back at a later date to verify compliance.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 1) having C4 sleep in staff room at night and 2) the garage is being used for other things aside from what's approved in the fire clearance which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Within 24 hours, the licensee will notify the local fire department about C4 sleeping in the staff room temporarily, update C4's Needs and Service Plan, and issue a 30-day eviction notice. The licensee will ensure that the garage is being used as approved by the fire department only. Proof will be sent to CCLD by POC date.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/30/2025 12:26 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/30/2025 at 11:42 AM
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: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in having unlocked cough medicine which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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The licensee locked the cough syrup during the visit. 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/30/2025 12:26 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/30/2025 at 11:42 AM
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: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a FIrst Aid/ CPR certficiation for S4 which poses a potential health and safety risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
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The licensee agrees to have staff do First Aid/ CPR training and send proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
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