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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600176
Report Date: 07/14/2026
Date Signed: 07/14/2026 03:36:17 PM

Document Has Been Signed on 07/14/2026 03:36 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:HAILEY'S CARE HOMEFACILITY NUMBER:
075600176
ADMINISTRATOR/
DIRECTOR:		RIFORMO, MARIAFACILITY TYPE:
740
ADDRESS:3831 LA COLINA ROADTELEPHONE:
(510) 222-0945
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 6CENSUS: 5DATE:
07/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Maria Riformo, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 7/14/2026 at 1:30 pm, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced annual 1-year required inspection. LPA met with Administrator Maria Riformo and explained the purpose of the visit.

The administrator currently holds a certificate (#7001621740) that expires on 4/6/2027. The facility’s fire clearance was approved for six (6) residents, four (4) may be non-ambulatory and one (1) bedridden. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for residents is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents.

Hot water temperature in the residents shared bathroom was measured at 113.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. Smoke detectors and carbon monoxide combination were in operating condition during visit. Fire extinguisher was last purchased on 12/1/2025. First aid kit was observed to be complete. LPA reviewed two (2) staff and five (5) resident records. Emergency disaster plan was last reviewed on 7/14/2026.

Continued on LIC809C.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2026
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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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176
VISIT DATE: 07/14/2026
NARRATIVE
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Continued from LIC809.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/21/2026:


  • LIC610D: Emergency disaster plan
  • LIC500: Personnel Record

The following deficiencies were observed:
  • At 2:00 pm, LPA observed missing 20 hr training from S2.
  • At 2:15 pm, LPA observed R1, R2, R3, R4 and R5 had missing appraisal needs and services plan.
  • At 2:30 pm, LPA observed that there wasn't an updated quarterly fire drill conducted.
  • At 2:45 pm, LPA observed missing first aid certificate from S1 and S2.
  • At 3:00 pm, LPA observed that S2 did not have a health screening and Tb test completed.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with Maria. A copy of the appeal rights and this report provided.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/14/2026 03:36 PM - It Cannot Be Edited


Created By: Yasamin Brown On 07/14/2026 at 03:09 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: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in S2 not having an LIC503 Health Screening and TB test on file which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 07/21/2026
Plan of Correction
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By POC date, the Administrator agrees to have S2 get a completed health screening and TB test completed and submit a self-ceritifcation letter to CCLD.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2026 03:36 PM - It Cannot Be Edited


Created By: Yasamin Brown On 07/14/2026 at 03:09 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: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 that S2 has not completed the 20 hours of annual training which poses a potential health and safety risk to persons in care.
POC Due Date: 07/21/2026
Plan of Correction
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By POC date, the Administrator agrees to have S2 complete the required annual training and submit a self-ceritifcation letter to CCLD.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as 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 in S1 and S2 did not complete their first aid training which poses a potential health and safety risk to persons in care.
POC Due Date: 07/21/2026
Plan of Correction
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By POC date, the Administrator agrees to have S1 and S3 complete their first aid training and submit a self-ceritifcation letter to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/14/2026 03:36 PM - It Cannot Be Edited


Created By: Yasamin Brown On 07/14/2026 at 03:09 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: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

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 that all five residents did not have an updated appraisal needs and services plan which poses a potential health and safety risk to persons in care.
POC Due Date: 07/21/2026
Plan of Correction
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By POC date, the Administrator agrees to complete all five of the residents appraisal needs and service plans and submit a self-ceritifcation letter to CCLD.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in that the facility has not conducted any recent fire dills which poses a potential safety risk to persons in care.
POC Due Date: 07/21/2026
Plan of Correction
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By POC date, the Administrator agrees create a schedule to ensure fire drills will be completed quarterly and submit a self-ceritifcation letter to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2026


LIC809 (FAS) - (06/04)
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