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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201179
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:28:33 PM

Document Has Been Signed on 10/21/2022 12:28 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:ALIATAS CORPORATIONFACILITY NUMBER:
019201179
ADMINISTRATOR:ALFONSO, AMELIAFACILITY TYPE:
735
ADDRESS:42799 DEAUVILLE PARK CT.TELEPHONE:
(650) 255-9603
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 4DATE:
10/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Myrna Ruakvandee- House managerTIME COMPLETED:
12:40 PM
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 On 10/21/2022 at 9:40 AM, Licensing Program Analysts (LPAs) L. Fici and J. Clancy-Czuleger arrived unannounced to conduct a Pre-licensing, change of ownership inspection. LPAs met with Myrna Ruakvandee- House manager (HM) and explained the purpose of the visit. The facility currently has 4 clients who reside in the facility. At 10:05 AM, Administrator Amelia Alfonso arrived to the facility and greeted LPAs

LPAs toured facility with HM and administrator including but not limited to 4 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 72 degrees F and hot water temperature was maintained at 107.1 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 1/21/2022.

The following deficiencies were observed cited under previous licensed facility. Prior to licensure, the following shall be corrected and faxed to CCL.

At 10:00 AM, LPAs observed no window screen in common bathroom, and a cracked window in bedroom number one.
At 10:10AM, LPAs observed chemicals accessible to clients in care in garage.
At 10:20AM, LPAs observed no complaint poster posted in common area.

Continue on Lic809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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: ALIATAS CORPORATION
FACILITY NUMBER: 019201179
VISIT DATE: 10/21/2022
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Continued from Lic809

LPA will inform Central Application (CAB) Unit that facility is not ready to be licensed and will inform CAB when all deficiencies were corrected.

Exit interview conducted and copy of this report provided to Amelia Alfonso
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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