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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601532
Report Date: 12/15/2021
Date Signed: 12/15/2021 03:59:25 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:FORTUNE VILLAFACILITY NUMBER:
075601532
ADMINISTRATOR:BUNYI, LEONILAFACILITY TYPE:
740
ADDRESS:1785 BILLINGS RDTELEPHONE:
(925) 689-6551
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 3DATE:
12/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Marina SuriaoTIME COMPLETED:
12:05 PM
NARRATIVE
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On 12/15/2021 , Licensing Program Analysts (LPAs) L. Ibo J. Clancy- Czuleger arrived unannounced to conduct a case management inspection due to a change of ownership. LPAs met with staff Marina Suriao (Applicant/Administrator for Eastbay Villas), LPAs called Administrator Leonila Bunyi to informed the purpose of the visit, per Administrator Leonila Bunyi she is not available, L.Bunyi gave permission to LPAs to read report and give copy of the report to Applicant Marina Suriao.

During Pre-licensing Inspection & Case management inspection, LPAs observed the following deficiencies:



On 10:31 AM – LPAs observed nail polish remover and hydrogen peroxide on a kitchen drawer accessible to clients in care. This deficiency was cleared at 10:32 AM, Applicant Marina S. place both items on a lock cabinet.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.



Exit interview conducted with Marina Suriao. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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: FORTUNE VILLA
FACILITY NUMBER: 075601532
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2021
Section Cited

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Based on bservation the licensee did not comply with the section cited above on 10:31AM LPAs observed hydrogen peroxide and nail polish remover accesible to clients in care which poses an immediate health, safety or 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: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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