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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
011440427
Report Date:
04/17/2024
Date Signed:
04/18/2024 09:03:27 AM
Document Has Been Signed on
04/18/2024 09:03 AM
- 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:
CHARITYS RESIDENCE
FACILITY NUMBER:
011440427
ADMINISTRATOR:
MARYANN AQUINO LAGURA
FACILITY TYPE:
740
ADDRESS:
2933 MONTEREY BLVD
TELEPHONE:
(510) 482-2855
CITY:
OAKLAND
STATE:
CA
ZIP CODE:
94602
CAPACITY:
6
CENSUS:
3
DATE:
04/17/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:15 PM
MET WITH:
Maryann Lagura
TIME COMPLETED:
06:10 PM
NARRATIVE
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On this day at around 12:15 pm, LPA Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with House Manager Caridad Aquino. LPA explained to Aquino the purpose of the visit. The Administrator arrived to the facility at a later time.
During the visit, LPA inspected the facility inside and out including but not limited to kitchen, dining and living area, garage, resident rooms, bathrooms and backyard. LPA observed the facility has sufficient supply of perishable and non perishable foods.
Smoke detectors were last inspected in 2023. Carbon monoxide was tested and observed operational. There were multiple fire extinguishers observed that were last serviced in 2022.
The facility was unable to provide resident files to the LPA. LPA reviewed 4 staff files. First aid kit was observed complete. There is no proof of last disaster drill conducted. All staff do not have current First aid/CPR training. Cleaning chemicals were observed unlocked in the laundry area. Knives were observed unlocked in a cabinet in the kitchen. Medication was observed unlocked in the refrigerator.
The following records need to be submitted to CCL by April 30, 2024: Lic 610E, Infection Control Plan, Roster of Residents, Lic 500, Liability Insurance and Disaster Drill.
Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).
Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
04/17/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/17/2024
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
12
Document Has Been Signed on
04/18/2024 09:03 AM
- 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:
CHARITYS RESIDENCE
FACILITY NUMBER:
011440427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observaiton, the licensee did not comply with the section cited above in failing to maintain a clean, safe, sanitary and in good repair facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/15/2024
Plan of Correction
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2
3
4
By POC date, the Administrator will notify LPA completion of POC. LPA will need to comeback to verify completion.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in locking glass emergency exit door which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/17/2024
Plan of Correction
1
2
3
4
The door was unlocked during the visit.
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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
04/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/17/2024
LIC809
(FAS) - (06/04)
Page:
2
of
12
Document Has Been Signed on
04/18/2024 09:03 AM
- 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:
CHARITYS RESIDENCE
FACILITY NUMBER:
011440427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having medication and knives unlocked and accessible to resident's which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/18/2024
Plan of Correction
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3
4
By POC date, Administrator will lock all items that could pose a danger to the residents and inform LPA of completion of POC.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review], the licensee did not comply with the section cited above in not having any staff with current First aid/CPR training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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2
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4
All staff will complete first aid/CPR and submit proof to CCL by POC date.
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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
04/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/17/2024
LIC809
(FAS) - (06/04)
Page:
3
of
12
Document Has Been Signed on
04/18/2024 09:03 AM
- 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:
CHARITYS RESIDENCE
FACILITY NUMBER:
011440427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in failing to maintain cleanliness in the kitchen area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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2
3
4
The kitchen area will get cleaned and free from any insects and notify LPA. LPA will have to come back to verify completion of POC.
Section Cited
Incidental Medical and Dental Care Services
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
04/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/17/2024
LIC809
(FAS) - (06/04)
Page:
4
of
12
Document Has Been Signed on
04/18/2024 09:03 AM
- 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:
CHARITYS RESIDENCE
FACILITY NUMBER:
011440427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in keeping medications in a cabinet without lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/18/2024
Plan of Correction
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2
3
4
The Administrator will lock all medications and notify LPA of completion of POC.
Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in not having any resident record available during inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/23/2024
Plan of Correction
1
2
3
4
The Administrator will complete all resident files and notify LPA of completion by POC date.
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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
04/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/17/2024
LIC809
(FAS) - (06/04)
Page:
5
of
12
Document Has Been Signed on
04/18/2024 09:03 AM
- 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:
CHARITYS RESIDENCE
FACILITY NUMBER:
011440427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in not having an updated Emergency Disaster Plan which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/23/2024
Plan of Correction
1
2
3
4
Administrator will submit to CCL an updated Disaster Plan.
Section Cited
Postural Supports
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
04/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/17/2024
LIC809
(FAS) - (06/04)
Page:
6
of
12
Document Has Been Signed on
04/18/2024 09:03 AM
- 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:
CHARITYS RESIDENCE
FACILITY NUMBER:
011440427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having window screens with cobwebs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/30/2024
Plan of Correction
1
2
3
4
The Administrator will get window screens cleaned and notify LPA by POC date.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in not having hot water which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
1
2
3
4
Administrator will get the water heater fixed and notify LPA once completed.
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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
04/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/17/2024
LIC809
(FAS) - (06/04)
Page:
7
of
12
Document Has Been Signed on
04/18/2024 09:03 AM
- 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:
CHARITYS RESIDENCE
FACILITY NUMBER:
011440427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(4)
Personal Accommodations and Services
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having a ramp with missing wood/uneven surgace which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/15/2024
Plan of Correction
1
2
3
4
The Administrator will get ramp fixed and notify CCL of completion.
Type B
Section Cited
CCR
87308(c)
Resident and Support Services
(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in not having sufficient storage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/15/2024
Plan of Correction
1
2
3
4
The Administrator will ensure that there is sufficient storage for equipment and supplies and notify CCL BY POC date.
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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
04/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/17/2024
LIC809
(FAS) - (06/04)
Page:
8
of
12
Document Has Been Signed on
04/18/2024 09:03 AM
- 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:
CHARITYS RESIDENCE
FACILITY NUMBER:
011440427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on file review, the licensee did not comply with the section cited above in not having proof of training available during inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/30/2024
Plan of Correction
1
2
3
4
The Administrator will send to CCL proof of staff training mentioned above.
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having proof of training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/30/2024
Plan of Correction
1
2
3
4
Administrator will submit to CCL proof of training for the above requirement.
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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
04/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/17/2024
LIC809
(FAS) - (06/04)
Page:
9
of
12
Document Has Been Signed on
04/18/2024 09:03 AM
- 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:
CHARITYS RESIDENCE
FACILITY NUMBER:
011440427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
87465(e)(2)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above in not having doctor orders for the residents' medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/30/2024
Plan of Correction
1
2
3
4
The Administrator will obtain medication order from each resident's doctor and notify CCL by POC date.
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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
04/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/17/2024
LIC809
(FAS) - (06/04)
Page:
10
of
12