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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201049
Report Date: 02/28/2024
Date Signed: 02/28/2024 01:15:58 PM

Document Has Been Signed on 02/28/2024 01:15 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: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: 5DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lilibeth LopezTIME COMPLETED:
01:30 PM
NARRATIVE
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On this day at around 10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Lilibeth Lopez. LPA explained to Lopez the purpose of the visit. Lopez contacted the Administrator about the visit.

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 4i home vendorized by the Regional Center of the East Bay (RCEB). It has an approved fire clearance for 6 ambulatory clients. LPA observed a fire extinguisher that appeared full and was last serviced on 10/12/2023. 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 105 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. P&I money and log were checked. LPA observed the facility has sufficient amount of surety bond to cover amount of money being handled at one time. The facility's last fire drill was conducted on 2/20/2024 and last earthquake drill was completed on December 17, 2023 .

During the visit, LPA observed C5 using a four wheel walker.

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 was conducted with Lopez. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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
Document Has Been Signed on 02/28/2024 01:15 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/28/2024 at 12:56 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: HAWAII HOME INC
FACILITY NUMBER: 019201049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

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 C5 who uses a walker stay in an ambulatory room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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By POC date, Administrator states C5 will be transferred to one of the facilities that has an approved nonambulatory fire clearance and will notify LPA. The Administrator will notify Union City Fire Department today regarding C5 pending transfer.
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: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024


LIC809 (FAS) - (06/04)
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