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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200670
Report Date: 01/18/2023
Date Signed: 01/18/2023 05:27:18 PM


Document Has Been Signed on 01/18/2023 05:27 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:ACAPULCO SENIOR CARE HOMEFACILITY NUMBER:
019200670
ADMINISTRATOR:KA, NINFACILITY TYPE:
740
ADDRESS:14160 ACAPULCO ROADTELEPHONE:
(510) 924-7457
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:6CENSUS: 2DATE:
01/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Elmore Shipley, Care StaffTIME COMPLETED:
05:40 PM
NARRATIVE
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On 1/18/2023 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with care staff, Elmore Shipley.

While LPA was conducting a complaint investigation, the following deficiency was observed.


LPA observed S1 was not fingerprint cleared and administrator, Joyce Rodriguez stated S1 started at the facility on Monday (1/16/2023) of this week. Civil penalty of $300 is being assessed.


The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.


Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
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 2


Document Has Been Signed on 01/18/2023 05:27 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: ACAPULCO SENIOR CARE HOME
FACILITY NUMBER: 019200670

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2023
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review...prior to working...Obtain a California clearance or a criminal record exemption... This requirement is not met as evidence by:
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Care staff that was fingerprint cleared came back to the facility and S1 left the facility during LPA's visit. Facility has agreed to obtain S1 fingerprint cleared immediately and will submit documents to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by having a non-fingerprinted staff work at the facility which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $300 is being assessed.

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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2