<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200625
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:09:54 PM


Document Has Been Signed on 05/17/2022 02:09 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MY FAMILY'S CARE HOME LLCFACILITY NUMBER:
079200625
ADMINISTRATOR:CAPUYAN, ISRAEL RFACILITY TYPE:
740
ADDRESS:2073 SOUTHWOOD DRIVETELEPHONE:
(510) 334-6933
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:4CENSUS: 2DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Israel Capuyan, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/17/2022 at 1:20 pm Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived to conducted a Case Management visit reported to CCLD. LPA met with Israel Capuyan and explained the purpose of the visit.

While LPAs were conducting a complaint investigation 15-AS-20220510152635 on 5/17/2022 during observation LPAs observed facility has 3 bedrooms 2 of the 3 bedrooms had residents 1 bedroom was empty. During interview S1 stated S2 resides at the facility, and sleeps in common area on a mattress.

The deficiencies was observed (see LIC809D and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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 05/17/2022 02:09 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: MY FAMILY'S CARE HOME LLC
FACILITY NUMBER: 079200625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2022
Section Cited

1
2
3
4
5
6
7
87307 Personal Accommodations and Services(a) Living accommodations and grounds shall be related to the facility's function.
This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA's observation licensee did not comply with the section cited above by allowing staff to sleep on a mattress (that's stored in the garage) in the living room common area. Which poses a potential health and safety risk to residents.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2