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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201179
Report Date: 11/26/2024
Date Signed: 11/26/2024 01:17:12 PM

Document Has Been Signed on 11/26/2024 01:17 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
OAKLAND ASC, 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:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Amelia Alfonso, Back-Up Administrator TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 11/26/2024 at 9:25 AM Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Care Staff, Linda Alina, who phoned the back up Administrator the purpose of our visit. The back up Administrator, Amelia Alfonso, arrived shortly after. The facility’s fire clearance was approved for all six (6) ambulatory only.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. There are no bodies of water. LPAs 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 114.3 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's and linen supplies was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply. Outdoor activity space was observed furnished with tables, chairs and shade.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/20/2024. First aid kit was observed to be complete. Emergency Disaster Drill was last posted on 07/22/2024. Fire Drill was last conducted on 07/06/2024.

At 9:35 AM, 4 of 4 clients records were reviewed. At 10:05 AM, 4 staff records were reviewed and 4 of 4 associated to the facility. At 11:30 AM, LPAs reviewed client's P&I money with log and there was no discrepancies observed. LPAs reviewed 4 of client's medications. All records were observed to be complete and up to date.

Continue to LIC809C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ALIATAS CORPORATION
FACILITY NUMBER: 019201179
VISIT DATE: 11/26/2024
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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 12/06/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan
Liability Insurance
Drivers License, Car Registration/ Insurance


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 with back up Administrator. Appeal Rights, LIC421IM, and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 11/26/2024 01:17 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/26/2024 at 12:19 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having the scissors and knives unlocked and accessible to clients which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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3
4
Staff locked the cabinet during the visit. Deficiency cleared during the visit.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in not obtaining a fire clearance in the additional client room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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The Licensee states Lic 200 and updated sketch will be submitted to CCL by POC date.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/26/2024 01:17 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/26/2024 at 12:19 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 having bed frames, mattress, chairs, and puddles in the backyard which poses a potential health and safety risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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Administrator agrees to remove the items from the backyard and send a proof of picture to CCLD by POC date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 by not having First Aid Certificate for S1 and S3 which poses a potential health and safety risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Administrator agrees to obtain First Aid Certificate for S1 and S3 and provide documents to CCLD by POC date.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/26/2024 01:17 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/26/2024 at 12:24 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80086(a)
(a)Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change

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 by having alterations made and did not inform licensing which poses an immediate health and safety risk to persons in care. The facility added a client room without notifying CCL.
POC Due Date: 11/27/2024
Plan of Correction
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The Licensee states Lic 200 and updated sketch will be submitted to CCL 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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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