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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600176
Report Date: 07/08/2024
Date Signed: 07/08/2024 11:58:22 AM


Document Has Been Signed on 07/08/2024 11:58 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:HAILEY'S CARE HOMEFACILITY NUMBER:
075600176
ADMINISTRATOR:RIFORMO, MARIAFACILITY TYPE:
740
ADDRESS:3831 LA COLINA ROADTELEPHONE:
(510) 222-0945
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 3DATE:
07/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maria Riformo, Licensee/AdministratorTIME COMPLETED:
12:20 PM
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On 07/08/2024 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Caregiver Maria Del Rosario who telephoned Licensee/Administrator (ADM), Maria Riformo and explained the purpose of the visit. ADM arrived at the facility shortly after.

On 07/02/2024 Administrator emailed LPA stating, “I have received all the records. To comply with the regulations, I’ll send you all the corrections on the due date”.

Facility has the following deficiencies that was not cleared resulting in civil penalties:

· HSC 1569.618(c)(3) - 3 days x $100 = $300.00


· HSC 1569.311 - 3 days x $100 = $300.00

ADM replaced Fire Extiinguisher that was observed full and carbon monoxide unit was in working condition. Civil Penalties in the total amount of $600.00 are assessed 07/08/2024 for failure to meet POC date for all deficiencies cited above. Facility is subject to ongoing daily civil penalties until deficiencies are corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2024
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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