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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601425
Report Date: 07/28/2023
Date Signed: 07/28/2023 12:37:22 PM


Document Has Been Signed on 07/28/2023 12:37 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: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: 6DATE:
07/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michael David ManarangTIME COMPLETED:
12:45 PM
NARRATIVE
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On 7/28/2023 at 11:30 AM, Associate Governmental Program Analyst (AGPA) L. Francisco conducted a case management while at the facility for another matter. AGPA met with Care Staff, Michael Bryan Manarang.

During record review, AGPA observed S2 and S3 are fingerprint cleared, but not associated to the facility. Care staff stated Administrator is out of town and won't return until 8/5/23.

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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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 07/28/2023 12:37 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: CRUSE HOUSE ALOHA
FACILITY NUMBER: 075601425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2023
Section Cited
CCR
87355(e)(2)

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CRIMINAL RECORD CLEARANCE
(e) All individuals subject to a criminal record review.. shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance..
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By POC date, Administrator will associate S2 and S3 when Administrator returns from vacation and submit proof of association to CCLD.
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This requirement is not met as evidenced by: Based on record review, S2 and S3 are not associated to the facility which poses a potential health, safety and personal rights risk to persons 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: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2