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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601425
Report Date: 01/19/2022
Date Signed: 01/19/2022 02:22:14 PM

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:CRUSE HOUSE ALOHAFACILITY NUMBER:
075601425
ADMINISTRATOR:REYES, VIRGIL T.FACILITY TYPE:
740
ADDRESS:1850 MARINA COURTTELEPHONE:
(925) 338-2056
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 5DATE:
01/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Orlando Decusar, Care StaffTIME COMPLETED:
02:35 PM
NARRATIVE
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On 1/19/2022 at 1:20 PM, Licensing Program Analyst (LPA) L. Francisco conducted a Case Management visit while at the facility for another matter. LPA met with Care Staff, Orlando Decusar and explained the purpose of the visit. LPA spoke to Adminstrator over the phone.

LPA observed S1 is not fingerprint cleared. Based on interview with S1, S2 and S3, S1 is helping cook for the residents and is helping feed R1.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator over the phone. Appeal Rights and a copy of this report provided with Care Staff.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CRUSE HOUSE ALOHA
FACILITY NUMBER: 075601425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2022
Section Cited

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(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:

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Based on record review, Licensee did not comply with the regulation cited above. LPA observed S1 is not fingerprint cleared and is helping cook for the residents and feed R1 which poses an immediate health and safety risk to resindents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2022
LIC809 (FAS) - (06/04)
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