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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201296
Report Date: 01/14/2025
Date Signed: 01/14/2025 03:37:31 PM

Document Has Been Signed on 01/14/2025 03:37 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:TINS ADULT DAY PROGRAMFACILITY NUMBER:
019201296
ADMINISTRATOR/
DIRECTOR:		ILAO, CRISTINAFACILITY TYPE:
775
ADDRESS:33131 ALVARADO NILES RDTELEPHONE:
(650) 580-5111
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 30CENSUS: 27DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Cristina Ilao, Program Director TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 01/14/2025 at 1:25 PM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Program Director, Christina Ilao, and explained the purpose of the visit. Day program operates from Monday to Friday 9:00 AM to 2:30 PM.

During the visit, LPAs inspected the Adult Day Program (ADP) including but not limited to bathrooms, activity rooms such as Arts and Crafts, Media , and Music Room. Hot water temperature measured at 120 degrees Fahrenheit in one client bathroom. There were fire extinguishers observed and last serviced on 11/01/2024. Room temperature was observed at 72 degrees Fahrenheit.

LPA reviewed 5 staff and 6 client files. All staff are fingerprint cleared and associated to the ADP.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 1:45 PM, LPAs observed wooden table blocking the emergency exit door.

At 1:50 PM, LPAs observed scissors in the kitchen unlocked

At 2:10 PM, LPAs observed that there was 18 clients that was non ambulatory and the facility is only approved for 15 non ambulatory clients. Facility is over capacity. Civil penalty of $500 is being assessed.

At 2:54 AM, LPAs observed that S2, S4, and S5 does not have the TB test result on file.

At 2:56 PM, LPA observed that S3 and S5 does not have First Aid Certification and CPR.

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 was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 5
Document Has Been Signed on 01/14/2025 03:37 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/14/2025 at 03:03 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: TINS ADULT DAY PROGRAM
FACILITY NUMBER: 019201296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which 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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Based on observation, the licensee did not comply with the section cited above in having scissors left on the table that was accessible to clients in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Staff removed the scissors. Deficiency cleared during the visit.
Type A
Section Cited
CCR
82087(c)
Buildings 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 a wooden table in front of the Emergency Exit Only door which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Staff removed the wooden table away from the Emergency Exit Only Door. Deficiency cleared during the visit.
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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/14/2025 03:37 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/14/2025 at 03:03 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: TINS ADULT DAY PROGRAM
FACILITY NUMBER: 019201296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82020
Fire Clearance
All day programs shall secure through the licensing agency 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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Based on observation, the licensee did not comply with the section cited above in having over capacity of non ambulatory clients in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Administrator will submit to CCL schedule of clients to ensure only 15 non ambulatory clients are physically present in the day program per day. Also, Administrator will submit self-certification of compliance to the fire clearance. Proofs 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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/14/2025 03:37 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/14/2025 at 03:03 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: TINS ADULT DAY PROGRAM
FACILITY NUMBER: 019201296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(g)(1)
Personnel Requirements
(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

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 a TB test result for S2, S4, and S5 on file which poses a potential health and safety risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Administrator agrees to obtain a TB test for all the staff and send proof to CCLD by POC date.
Type B
Section Cited
CCR
82075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation 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 S3 and S5 CPR and First Aid on file which poses a potential health and safety risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Administrator agrees to obtain First Aid and CPR training for the staff and send proof 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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5