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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201008
Report Date: 10/05/2021
Date Signed: 10/05/2021 04:50:42 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:TEMESCAL RESIDENTIAL CARE HOME CORP.FACILITY NUMBER:
079201008
ADMINISTRATOR:MELANIO, ANDRES JR JAGARAPFACILITY TYPE:
740
ADDRESS:4580 TEMESCAL COURTTELEPHONE:
(925) 813-5700
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 6DATE:
10/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Andres "Jay" Melanio, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On 10/05/21 at 3:30PM, Licensing Program Analyst (LPA) conducted an unannounced case management during the annual infection control inspection and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

LPA observed staff (S1, S2 and S3) were not listed in LIS personnel summary dated 10/05/21. During visit, LPA reviewed staff (S1, S2 and S3) files. LPA observed S1, S2 and S3 had completed criminal record statements (LIC 508), live scan records and criminal background transfer request forms (LIC 9182) that were not processed in the Guardian Portal. This was confirmed by ADM.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC 9099 D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.



SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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: TEMESCAL RESIDENTIAL CARE HOME CORP.
FACILITY NUMBER: 079201008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2021
Section Cited

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(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility.
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This requirement was not met as evidenced by staff (S1, S2 and S3) not associated to the facility which posed a potential health & safety risk to residents 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: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2021
LIC809 (FAS) - (06/04)
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