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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201179
Report Date: 05/01/2024
Date Signed: 05/01/2024 02:41:26 PM

Document Has Been Signed on 05/01/2024 02:41 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/
DIRECTOR:		UY, RONALDFACILITY TYPE:
735
ADDRESS:42799 DEAUVILLE PARK CT.TELEPHONE:
(650) 255-9603
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 4DATE:
05/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Myrna Ruakvandee- House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 5/01/24 at 1:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Myrna Ruakvandee- House Manager and explained the purpose of the visit

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70-degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the kitchen sink was measured at 123.3-degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of one-week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 2/20/24. First aid kit was observed to be complete. Fire drill was last conducted on 3/15/24.

LPA reviewed 4 clients’ records and 4 staff records, and all were complete. 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.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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 05/01/2024 02:41 PM - It Cannot Be Edited


Created By: Gregory Clark On 05/01/2024 at 02:30 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: ALIATAS CORPORATION
FACILITY NUMBER: 019201179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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. Hot water measured at the kitchen sink was 123.3 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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Administrator to send a photo of water temperature measured at the kitchen sink with-in the regulatory range by POC 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Gregory Clark
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
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