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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201111
Report Date: 04/06/2023
Date Signed: 04/06/2023 05:34:23 PM

Document Has Been Signed on 04/06/2023 05:34 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:MILA'S HOMEFACILITY NUMBER:
019201111
ADMINISTRATOR:YAMBAO, JOAQUIN ALEJANDROFACILITY TYPE:
735
ADDRESS:968 FOLSOM AVETELEPHONE:
(925) 337-9199
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
04/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Joaquin Alejando YambaoTIME COMPLETED:
05:45 PM
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On 4/6/2023 at approximately 12:30 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection and met with Administrator Joaquin Alejandro Yambao.
LPA explained to Administrator purpose of the visit.

The facility has a fire clearance approved for 4 ambulatory clients. Upon arrival, LPA was informed that 3 clients are at their respective day programs and one client at the doctor's office for an appointment. The facility has 4 2 bedrooms and 2 bathrooms. There are 2 male and 2 female clients. The facility is Regional Center of the East Bay (RCEB) Level 4i vendored. There were 3 staff observed during the shift.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, backyard. Hot water measured at 188 F in the bathroom and kitchen. There was sufficient supply of perishable and non perishable foods. Knives and other sharp objects were observed in a locked box. Medications were locked in a cabinet not accessible to clients. Smoke detectors and carbon monoxide were tested and observed operational. There are no bodies of water observed.

At around 2pm, LPA reviewed 2 staff and 2 client files. At 3pm, LPA reviewed Medication Administration Record (MAR) and medication bottles.

At around 3:30pm, LPA and Administrator reviewed P&I money and log. At 4:30pm, LPA interviewed 2 staff and attempted to interview 2 clients.

Type B deficiency is noted during the visit.

A copy of this report was provided to Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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Document Has Been Signed on 04/06/2023 05:34 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 04/06/2023 at 05:15 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: MILA'S HOME
FACILITY NUMBER: 019201111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023

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


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 for not having sufficient bond. Amount of surety bond is $1, 000. However, facility has $6,572.00 total amount of money handled.
POC Due Date: 04/12/2023
Plan of Correction
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By POC date, facility will upgrade bond and send a copy to CCL.
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: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023


LIC809 (FAS) - (06/04)
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