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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200334
Report Date: 07/08/2021
Date Signed: 07/08/2021 04:57:15 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:AMAZING HOME CARE IIFACILITY NUMBER:
079200334
ADMINISTRATOR:MARILOU SOLOMONFACILITY TYPE:
740
ADDRESS:5017 SAINT GARRETT COURTTELEPHONE:
(925) 671-7909
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 3DATE:
07/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Adonis Solomon/LicenseeTIME COMPLETED:
05:00 PM
NARRATIVE
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While a the facility for a complaint (Control # 15-AS-20201014161515) and upon observation, interview and review of staff roster, LPA learned that Almarie Solomon, staff, although fingerprint cleared, is not associated to the facility. Almarie has been coming to the facility since last year and not associated up to this day, July 8, 2021.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction (POC) by plan of correction due date along with the LIC9098 Proof of Correction and any repeat violations within 12-month period may result in civil penalties.

Deficiency and plan and proof of corrections were discussed with Adonis Solomon, licensee.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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: AMAZING HOME CARE II
FACILITY NUMBER: 079200334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2021
Section Cited

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87355 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 as specified in Section 87355(c).

-This requirement is not met as evidenced by:
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-Based on observation, interview and review of record, the licensee did not comply with the above Regulation by not having Almarie Solomon associated which poses potential safety 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2021
LIC809 (FAS) - (06/04)
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