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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201111
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:20:17 PM

Document Has Been Signed on 04/18/2024 02:20 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MILA'S HOMEFACILITY NUMBER:
019201111
ADMINISTRATOR/
DIRECTOR:		YAMBAO, JOAQUIN ALEJANDROFACILITY TYPE:
735
ADDRESS:968 FOLSOM AVETELEPHONE:
(925) 337-9199
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Joaquin Yambao, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 04/18/2024 at 11:10 AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Direct Support Professional, Jeseca Larosa and explained the purpose of the visit. Jeseca called Administrator, Joaquin Yambao to inform. Joaquin arrived shortly after. The facility’s fire clearance was approved for capacity of four (4) Ambulatory residents. Administrator's certificate #6059926735 expires 02/08/2025.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 2 total bedrooms which 2 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degree Fahrenheit. LPA 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 116.6 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene supplies were available for clients.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased 02/05/2024. Emergency Disaster Drill was last posted on 04/07/2024. First aid kit was complete.

LIC809-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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 04/18/2024 02:20 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 04/18/2024 at 01:34 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator agrees to go grocery shopping today and purchase more food (snacks, fruits, canned fruits/veggies, canned foods, meats) for the house and will submit a photo copy of receipts and food to CCLD by POC due 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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MILA'S HOME
FACILITY NUMBER: 019201111
VISIT DATE: 04/18/2024
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LIC809-C Continued...

Four clients' records were reviewed. Three staff records were reviewed, and 3 of 3 have current first aid training and associated to the facility. A sample of 2 client’s medications were reviewed.

The following deficiencies were observed (see LIC 809D) and 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.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/25/2024:

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
Liability Insurance

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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