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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201049
Report Date: 02/26/2025
Date Signed: 02/26/2025 03:57:56 PM

Document Has Been Signed on 02/26/2025 03:57 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/
DIRECTOR:		MARCELO, TYLERJAMES A.FACILITY TYPE:
735
ADDRESS:3222 SAN PEDRO WAYTELEPHONE:
(510) 921-1988
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 3DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Lilibeth LopezTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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On this day at around 2:15 pm , 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.

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 10/17/2024. 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 supply of warm blankets, sheets and towels available for use of the clients. First aid kit was observed complete and updated. Medications were observed locked in a cabinet in the hallway. Hot water measured at 113.5 degrees Fahrenheit.

LPA reviewed 3 staff and 4 client files at around 2:45 pm. All staff were observed fingerprint cleared and associated to the facility. Staff have current First Aid and CPR training. At around 3:10 pm, 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 1/5/2025 and last earthquake drill was completed on 1/6/2025.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HAWAII HOME INC
FACILITY NUMBER: 019201049
VISIT DATE: 02/26/2025
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At 3:25 pm, medications and Medication Administration Record (MAR) were reviewed.

The following forms were received during the visit: Disaster Plan, Infection Control Plan, Liability insurance, Lic 308, Vehicle Registration/insurance/driver's license.

There is no deficiency noted for this visit.

A copy of this report was provided to Lopez.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
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