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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601472
Report Date: 03/03/2021
Date Signed: 03/03/2021 10:19:07 AM

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:WELCOME HOME SENIOR RESIDENCE (ALAMO II)FACILITY NUMBER:
075601472
ADMINISTRATOR:CHOU, SETEVE & GALLO, CFACILITY TYPE:
740
ADDRESS:10 CASTLE CREST ROADTELEPHONE:
(510) 685-8388
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: 4DATE:
03/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Steve Chou, AdministratorTIME COMPLETED:
09:50 AM
NARRATIVE
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On 03/03/2021 at 09:20am Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on January 26, 2021. LPA informed Steve Chou, Administrator that due to Shelter in Place Order, this case management will be conducted via video conference. LPA met with Steve Chou, Administrator and explained the purpose of the visit.

On October 30, 2020 Cardinal Care Management, was provided a letter of engagement by the Department’s Auditor and requested the following documents be mailed, faxed, scanned, or emailed no later than December 1, 2020 to CCLD Audit Section.

· LIC401 Monthly operating statement & LIC401A supplemental financial information.
· LIC403 Balance sheet & LIC403A balance sheet supplemental schedule.

However, the documents were never received.

Based on the information obtained by the Department, a deficiency is cited per California Code of Regulations, Title 22, and listed on LIC809D. Failure to submit Proof of Corrections (POC's) by Plan of Correction date may result in civil penalties.

Exit interview conducted a copy, appeal rights, and CCLD engagement letter provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021
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: WELCOME HOME SENIOR RESIDENCE (ALAMO II)
FACILITY NUMBER: 075601472
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2021
Section Cited

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87213 Finances. The licensee shall have a financial plan…that assures sufficient resources...maintain adequate financial records...submit such financial reports as may be required…This requirement was not met as evidence by:


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Based on LPA's review licensee did not comply with the section cited above which poses a potential health and safety risk to the residents.
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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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2021
LIC809 (FAS) - (06/04)
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