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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201200
Report Date: 01/23/2025
Date Signed: 01/23/2025 02:23:54 PM

Document Has Been Signed on 01/23/2025 02:23 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:OHANA HOME CAREFACILITY NUMBER:
019201200
ADMINISTRATOR/
DIRECTOR:		RIEZA, DEBBIEFACILITY TYPE:
735
ADDRESS:2424 ALMADEN BLVDTELEPHONE:
(925) 872-6836
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 3DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Debbie Rieza, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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On 01/23/2025 at 12:40 PM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with back up Administrator, Irish Arenas, and explained the purpose of the visit. Administrator, Debbie Rieza, came shortly later to sign the report. The facility’s fire clearance was approved for all four non-ambulatory.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which all bedrooms are occupied by the clients. There are no bodies of water. A comfortable temperature for clients is maintained at 68 degree Fahrenheit. 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 105 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/03/2024. Emergency Disaster Drill was last conducted on 12/02/2024. First aid kit was observed to be complete. Fire drill was last conducted on 10/05/2024.

At 12:55, 3 of clients records were reviewed. At 1:28 PM, 3 staff records were reviewed. All 3 have current first aid training and are associated to the facility. LPAs reviewed client's P&I money with log. LPAs reviewed client's medications. All records were observed to be complete and up to date.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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: OHANA HOME CARE
FACILITY NUMBER: 019201200
VISIT DATE: 01/23/2025
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/30/2025:

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
Driver's License/ Auto Insurance/ Auto Registration

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 1:15 PM, LPAs observed two ladder steps blocking side exit in the garage.

The Facility was 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 Staff. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 02:23 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/23/2025 at 02:05 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: OHANA HOME CARE
FACILITY NUMBER: 019201200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 two ladder steps blocking the exit side door in the garage which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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The ladder steps was removed from the passageway. Deficiency cleared during the visit.
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: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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