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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201193
Report Date: 12/06/2023
Date Signed: 12/06/2023 02:20:05 PM

Document Has Been Signed on 12/06/2023 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:RACHELL'S FACILITYFACILITY NUMBER:
019201193
ADMINISTRATOR:EVANS, RACHELLFACILITY TYPE:
735
ADDRESS:33103 8TH STREETTELEPHONE:
(510) 331-2598
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 2DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mirzett/Rachell EvansTIME COMPLETED:
02:30 PM
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On this day at around 10:45am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection and met with House Manager Mirzett Evans. Administrator was informed about the visit by telephone and authorized Mirzett to sign reports. Administrator arrived at the facility at a later time.

During the visit, LPA inspected the facility inside and out including but not limited to 3 client rooms, common areas, garage and backyard. The facility is licensed for 4 ambulatory clients. The facility is a Level 4i vendorized by the Regional Center of the East Bay (RCEB). Upon arrival, one client was observed at the facility. Evans states the other client goes to Washington High School.

Hot water temperature measured at 105 degrees Fahrenheit. Fire extinguisher appeared full and was last inspected on 1/19/2023. Interconnected dual carbon monoxide and smoke detectors were tested and observed operational. There was sufficient supply of perishable and non perishable foods. Refrigerator temperature measured at 40 degrees Fahrenheit and freezer temperature was at -6 degrees Fahrenheit.
There were no bodies of water observed. Passageways were free from obstruction.

At around 11:20 am, LPA reviewed 2 client files and 2 staff files. At around 11:50 am, LPA interviewed one client and Administrator. During file review, LPA observed clients do not have current medical assessment.

Deficiency is cited per Title 22 California Code of Regulations.

Exit interview was conducted and Appeal Rights was provided.


SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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 12/06/2023 02:20 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 12/06/2023 at 02:12 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: RACHELL'S FACILITY
FACILITY NUMBER: 019201193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:

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 in not having medical assessments for the two clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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By POC date, Administrator will obtain updated Lic 602 for the clients and submit proof 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: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
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