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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201017
Report Date: 03/26/2021
Date Signed: 03/26/2021 02:34:37 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:AQUINO'S CARE HOMEFACILITY NUMBER:
079201017
ADMINISTRATOR:AQUINO, MARICELFACILITY TYPE:
740
ADDRESS:2481 RAMONA STREETTELEPHONE:
(559) 303-7020
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:6CENSUS: 3DATE:
03/26/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maricel Aquino, AdministratorTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Administrator Maricel Aquino. Due to the present shelter in place order by the Governor, this inspection was conducted via video-conference.

The purpose of this Case Management inspection was to follow-up with Administrator regarding her request for bedridden clearance. On 3/23/21, Administrator informed LPA Singh that R1 was bedridden and on Hospice, however the facility's current Fire Clearance was only granted for six (6) Non-Ambulatory residents. LPA Singh immediately initiated an urgent Fire Clearance request for Administrator.

During today's inspection, LPA learned that R1 had passed away on the late evening of 3/23/21. LPA reviewed the remaining three (3) residents' Physician's Reports and all were deemed to be Non-Ambulatory. Administrator is no longer in pursuit of an urgent Fire Clearance for bedridden, however will be working with the Fire Department to obtain bedridden clearance for the future. Currently, an assessment of the facility is scheduled for 4/6/21 with the City of Pinole Fire Marshall.

No deficiencies cited during today's inspection. Exit interview conducted and a copy of this report emailed to Administrator
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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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