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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201049
Report Date: 01/28/2023
Date Signed: 01/28/2023 11:08:57 AM

Document Has Been Signed on 01/28/2023 11:08 AM - 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:HAWAII HOME INCFACILITY NUMBER:
019201049
ADMINISTRATOR:MARCELO, TYLERJAMES A.FACILITY TYPE:
735
ADDRESS:3222 SAN PEDRO WAYTELEPHONE:
(510) 921-1988
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 2DATE:
01/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Magalene David, CaregiverTIME COMPLETED:
11:15 AM
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On 01/28/2023 at 9:50AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Magalene David and explained the purpose of the visit. LPA text Administrator, Tyler Marcelo, and received return call at 10:50AM.

Upon entry, LPA's temperature was not checked. LPA observed screening station and mask sign on front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. LPA recommends step-on garbage cans for facility. Hot water temperature in the shared clients’ bathroom was measured at 134.5 degrees Fahrenheit. Fire extinguisher last serviced on 10/4/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke/carbon monoxide detector operable.

During record review, LPA observed facility has a copy of the infection control plan on file. LPA observed paper supplies are sufficient.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2023
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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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: HAWAII HOME INC
FACILITY NUMBER: 019201049
VISIT DATE: 01/28/2023
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Continued from LIC809.

LPA requested the following documents to be submitted to CCLD by 2/6/2023.
  • Administrator certificate
  • Emergency disaster plan (LIC610D).
  • Facility roster
  • Staff schedule (LIC500).


The following deficiency was observed:

-At 10:25AM, LPA observed a wood leaning against the home holding up the fence and blocking the passageway to the emergency pedestrian gate.

The 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 conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2023 11:08 AM - It Cannot Be Edited


Created By: Laura Hall On 01/28/2023 at 10:43 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: HAWAII HOME INC
FACILITY NUMBER: 019201049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings 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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Based on observation, the licensee did not comply with the section cited above in having the fence repaired and not blocking the passageway which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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Administrator agreed to get estimate for fence repair and submit copy or to repair fence and submit photos to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2023


LIC809 (FAS) - (06/04)
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