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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201233
Report Date: 08/16/2024
Date Signed: 08/16/2024 12:40:09 PM


Document Has Been Signed on 08/16/2024 12:40 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:CMA CARE HOME 1FACILITY NUMBER:
019201233
ADMINISTRATOR:ABOLENCIA, IMELDAFACILITY TYPE:
740
ADDRESS:4384 GIBRALTAR DRIVETELEPHONE:
(510) 573-0046
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 4DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Imelda Abolencia - Administrator TIME COMPLETED:
01:00 PM
NARRATIVE
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On 08/16/24 at 10:20 am Licensing Program Analysts (LPA) J. Clancy-Czuleger and P. Manalo arrived unannounced to do an annual inspection. LPA meet with Administrator Imelda Abolencia and explained the purpose of the visit.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 04/30/2024.

At 11:02 am LPA reviewed 4 residents records. At 11:45 am, LPA reviewed 2 staff records and 2 of 2 were fingerprint cleared and associated to the facility.

The following deficiency was observed during the visit:
R4 did not have an updated medical assessment.
R2 and R4 did not have updated TB test.

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/16/2024 12:40 PM - It Cannot Be Edited

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: CMA CARE HOME 1
FACILITY NUMBER: 019201233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

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 not having a medical assesment for R4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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The facility agrees to submit an updated medical assesment to CCLD by POC date.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

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 by not having 2 of the residents have their TB test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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The facility agrees to submit T.B tests for the residents 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2