015601017-6-19-2025-15-AS-PMAO-DHSQPC-20250619122032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601017
Report Date: 06/19/2025
Date Signed: 06/19/2025 12:21:05 PM

Document Has Been Signed on 06/19/2025 12:21 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	MISSION VILLA RESIDENTIAL CARE HOME		FACILITY NUMBER:	015601017
ADMINISTRATOR/ DIRECTOR:	RUBIO, MARISSA		FACILITY TYPE:	740
ADDRESS:	42423 PASEO PADRE PARKWAY		TELEPHONE:	(510) 656-0168
CITY:	FREMONT	STATE: CA	ZIP CODE:	94539
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	06/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Marissa Rubio, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:35 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 06/19/2025 at 9:00 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Marissa Rubio and explained the purpose of the visit. Administrator certificate is current. LPA toured facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 107.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 07/02/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/01/2025. At 9:50 AM, LPA reviewed 6 residents records. At 10:25 AM, LPA reviewed 4 staff records and 4 x 4 have current first aid training and associated to the facility. At 11:15 AM, LPA reviewed two sample of residents’ medications. At 11:45 AM, LPA reviewed resident's P&I money. Continue to LIC809-C...

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 06/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 06/19/2025 12:21 PM - It Cannot Be Edited

Created By: Patricia Manalo On 06/19/2025 at 11:45 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MISSION VILLA RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87216(a)(1)

(1) The amount of the bond shall be in accordance with the following schedule: Total Safeguarded Per Month Bond Required $750 or less $1,000 $751 to $1,500. $2,000 $1,501 to $2,500 $3,000 Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond. 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 by not having sufficient surety bond for the P&I money which poses a potential safety risk to persons in care.
	POC Due Date: 07/03/2025
	Plan of Correction
1 2 3 4	The Administrator will increase the surety bond and send proof to CCLD by POC date.

Section Cited


	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.

	Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (510) 286-4201

	Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (916) 432-7785

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC809 (FAS) - (06/04)

Page: 3 of 13

Document Has Been Signed on 06/19/2025 12:21 PM - It Cannot Be Edited

Created By: Patricia Manalo On 06/19/2025 at 11:54 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MISSION VILLA RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked 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 by having a knife by the kitchen sink unlocked which poses an immediate safety risk to persons in care.
	POC Due Date: 06/20/2025
	Plan of Correction
1 2 3 4	The Administrator locked the knife during the visit. Deficiency cleared.

Section Cited


	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.

	Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (510) 286-4201

	Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (916) 432-7785

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC809 (FAS) - (06/04)

Page: 4 of 13

Document Has Been Signed on 06/19/2025 12:21 PM - It Cannot Be Edited

Created By: Patricia Manalo On 06/19/2025 at 11:54 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MISSION VILLA RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 by not having a TB test for S4 which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/26/2025
	Plan of Correction
1 2 3 4	The Administrator will obtain S4's TB test and send proof to CCLD 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.

	Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (510) 286-4201

	Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (916) 432-7785

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC809 (FAS) - (06/04)

Page: 5 of 13

Document Has Been Signed on 06/19/2025 12:21 PM - It Cannot Be Edited

Created By: Patricia Manalo On 06/19/2025 at 11:54 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MISSION VILLA RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: 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 by having incomplete files for all the residents in care which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/03/2025
	Plan of Correction
1 2 3 4	The Administrator agrees to complete all residents' files and send proof to CCLD by POC date.

Section Cited


	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.

	Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (510) 286-4201

	Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (916) 432-7785

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC809 (FAS) - (06/04)

Page: 6 of 13

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MISSION VILLA RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601017
	VISIT DATE: 06/19/2025

NARRATIVE

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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/03/2025:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:19 AM, LPA observed a knife by the kitchen sink unlocked.

At 11:03 AM, LPA observed all residents' files incomplete.

At 11:44 AM, record review revealed the facility does not have sufficient Surety Bond to cover P&I money.

At 11:52 AM, LPA observed that S4 did not have TB test on file.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

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

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia Manalo	TELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC809 (FAS) - (06/04)

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