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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201466
Report Date: 05/26/2026
Date Signed: 05/26/2026 06:27:23 PM

Document Has Been Signed on 05/26/2026 06:27 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:ALONDRA CARE HOME 3FACILITY NUMBER:
019201466
ADMINISTRATOR/
DIRECTOR:		PASCUAL, JEZRAEL TFACILITY TYPE:
740
ADDRESS:27765 DECATURTELEPHONE:
(510) 391-1257
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 5DATE:
05/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:05 PM
MET WITH:Rosemarie Salas/Staff and
Jezrael Pascual/Administrator 		TIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On this day, May 26, 2026, at 4:05 pm., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Rosemarie Salas, and informed the reason for visit. LPA called and spoke over the phone with Thinn Aye, licensee. Licensee gave permission to Rosemarie Salas to be with LPA while doing inspection, because she can not come to the facility and Jezrael Pascual, administrator (ADM) is at her (licensee) other facility at the moment. ADM arrived at around 5:15 pm.

LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables.

Facility has smoke and carbon monoxide detectors that were tested and observed in operating condition during today's visit. Fire extinguisher was observed fully charge with tag showed serviced May 14, 2026. Hot water temperature in the common bathroom was tested.

LPA observed the following:
-at 4:16 pm, unlocked kitchen cabinet under the sink where Clorox and other cleaning agents were stored.
-at 4:17 pm, 3 bottles of Milk of Magnesia in the refrigerator.
-at 4:22 pm, Fabuloso cleaning agent in unlocked closet by the hallway.
-at 4:25 pm, Comet in cabinet in residents' ensuite bathroom.
-at 4:27 pm, Voltaren cream in one of residents' rooms.
-at 4:28 pm, CA-Rezz skin cream/ointment in the common bathroom.

...continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2026
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ALONDRA CARE HOME 3
FACILITY NUMBER: 019201466
VISIT DATE: 05/26/2026
NARRATIVE
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CONTINUED FROM PAGE 1:

-at 4:30 pm, hot water temperature at 123.3 degrees Fahrenheit.
-at 4:33 pm, staff medications in unlocked garage.
-at 4:34 pm, shovel in the side yard.
-staff (S1) who had been working for 5 days now is not fingerprint cleared.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for deficiency section #87309(a) for repeat violation within 12 month period. A $500.00 civil penalty is also assessed for section # 87355(e)(2) for staff who is not fingerprinted and will continue for $100.00 per day until corrected. Failure to submit proof of corrections by plan of correction due dates for other deficiencies cited may also result in civil penalties.

Deficiencies, plan and proof of corrections, and civil penalties were discussed with the administrator.

Due to time constraint, LPA will come back to continue the inspection.

Exit interview conducted. Appeal Rights, LIC421IM and LIC421FC Civil Penalties, LIC9098 Proof of Correction form and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/26/2026 06:27 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/26/2026 at 05:47 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: ALONDRA CARE HOME 3
FACILITY NUMBER: 019201466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 the cleaning agents in unlocked kitchen cabinet; unlocked Fabuloso, Voltaren ointment, CA-Rezz cream, Comet, shovel, staff medications which pose an immediate health, safety and/or personal rights risks to persons in care.
POC Due Date: 05/27/2026
Plan of Correction
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Administrator locked all the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/27/26.
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in staff (S1) not fingerprinted which poses an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 05/27/2026
Plan of Correction
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Administrator stated she'll have the staff fingerprinted and will not allow to work until cleared. Proof to be submitted by 5/27/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/26/2026 06:27 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/26/2026 at 05:47 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: ALONDRA CARE HOME 3
FACILITY NUMBER: 019201466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 hot water at 123.3 degrees Fahrenheit which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 06/09/2026
Plan of Correction
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Administrator to have the water temperature adjusted within Regulations range. Proof to be submitted by 6/09/26.
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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2026


LIC809 (FAS) - (06/04)
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