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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601499
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:50:42 PM


Document Has Been Signed on 09/27/2024 12:50 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:A NEW HAVEN CARE HOME - BERLINFACILITY NUMBER:
015601499
ADMINISTRATOR:ROBERT ABELLAFACILITY TYPE:
740
ADDRESS:1422 BERLIN WAYTELEPHONE:
(925) 344-7274
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
09/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Roberto 'Robert' Abella/Administrator TIME COMPLETED:
01:00 PM
NARRATIVE
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While conducting an investigation of a complaint (Control # 15-AS-20230523113154), the Department observed that staff’s (S1) fingerprint clearance was still in process (pending) as of 05/24/2023. Copy of S1’s LIC501 Personnel Record obtained from Arnold Soleta, licensee, showed 05/16/2023 as S1’s date of employment. S1 was fingerprint cleared and associated to other facility as of 03/07/2023 but not associated to A New Haven Care Home - Berlin. S1 was associated only on 05/25/2023.

On this day, September 27, 2024, Licensing Program Analyst (LPA) Delmundo conducted a case management as a result of the above. LPA met with Administrator (ADM) Roberto 'Robert' Abella. LPA called and spoke with Arnold Soleta, licensee, over the phone, and informed the reason for visit.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with licensee over the phone in the presence of ADM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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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Document Has Been Signed on 09/27/2024 12:50 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: A NEW HAVEN CARE HOME - BERLIN
FACILITY NUMBER: 015601499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review.......shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance.....
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The staff was associated to the facility on 5/25/23.

In addition, licensee and ADM to read the Regulations and send self-certification by 10/11/24.
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-This requirement is not met as evidenced by:

-Based on records review, the licensee did not comply with the section above in S1 working prior to being associated which posed an potential safety and/or personal rights risks to persons 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: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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