<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601221
Report Date: 04/09/2025
Date Signed: 04/09/2025 02:05:30 PM

Document Has Been Signed on 04/09/2025 02:05 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LARKEY PARK HOME CAREFACILITY NUMBER:
075601221
ADMINISTRATOR/
DIRECTOR:		CAMACLANG, ALBERTINA RFACILITY TYPE:
740
ADDRESS:2532 LARKEY LANETELEPHONE:
(925) 287-8590
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
04/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:09 AM
MET WITH:Jenny Lagana, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:20 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 04/09/2025 at 11:00 AM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management. LPA met with Caregiver, Jenny Lagana, and explained the purpose of the visit. Jenny phoned, Administrator, Tina Camaclang to inform.

LPA L. Alexander conducted an Annual Inspection on 12/03/2024 and cited for deficiencies. The Plan of Correction (POC) original due date was 12/17/2024, in which the Administrator requested an extension to the due date. LPA conducted a Case Management visit on 01/17/2025 in which there were deficiency cited for garage modification without a building permit.

LPA was unable conduct a POC visits for deficiencies cited on previous visits.
Deficiencies not cleared will be re-cited with a new POC due date.

Deficiencies cleared today:
  • CCR 87303(a) 12/20/2024
  • CCR 87632 (a) 01/13/2025
  • CCR 87632(d)(2) 03/04/2025
  • CCR 87705(c)(5) 03/04/2025
  • HSC 1569.618(c)(3) 04/08/2025
  • CCR 87618(b)(3)(A) 04/08/2025

LIC809-C Continued...
Bennett FongTELEPHONE: (510) 725-7919
Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
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 5
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)
Page: 2 of 5
Document Has Been Signed on 04/09/2025 02:05 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: LARKEY PARK HOME CARE
FACILITY NUMBER: 075601221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2025
Section Cited
CCR
87202(a)

1
2
3
4
5
6
7
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to submit LIC200 and Facility Sketch to CCLD by POC due date. In addition, notify Fire Department that there is a resident located in Room #5 and send a copy of notification to CCLD by POC due date.
8
9
10
11
12
13
14
Based on LPA's observation and interview the Licensee did not comply with the section cited above in by notifying Licensing and obtaining an approved fire clearance for a resident to be residing in Room #5 which poses a potential health and safety risk for persons in care.
8
9
10
11
12
13
14
Immediate Civil Penalty of $500.00 is assessed for violation.
Type A
04/10/2025
Section Cited
CCR87755(a)

1
2
3
4
5
6
7
87755 Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee or agent of the licensing agency may...enter and inspect the entire premise of any place providing services at any time...

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to get a copy of key and leave at the facility. Send a picture of key and where it will be located. In addition, Administrator shall self-certify reading/understanding/complying of regulation and send certification to CCLD by POC due date.
8
9
10
11
12
13
14
Based on LPA's observation and interview the Licensee did not comply with the section cited above in facility being accessible for Department, which poses a potential health and safety risk for persons in care.
8
9
10
11
12
13
14
Immediate Civil Penalty of $500.00 is assessed for violation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett FongTELEPHONE: (510) 725-7919
Lori Alexander-WashingtonTELEPHONE: (510) 285-3934

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025

LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/09/2025 02:05 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: LARKEY PARK HOME CARE
FACILITY NUMBER: 075601221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2025
Section Cited
CCR
87305(a)

1
2
3
4
5
6
7
87305 Alterations to Existing Building or New Facilities

(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to self-certify reading/understanding/complying with regulation and submit certifiaction to CCLD by POC due date. In addition, Administrator will submit to CCLD copy of building permit for modification/facility sketch to CCLD by POC due date.
8
9
10
11
12
13
14
Based on LPA's observation and interview the Licensee did not comply with the section cited above in by unauthorized modification of detached garage into a "storage" with a toilet which poses a potential health, safety and personal rights risk to clients in care.
8
9
10
11
12
13
14
Type B
04/15/2025
Section Cited
CCR87411(f)

1
2
3
4
5
6
7
87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health... Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician...The report shall indicate whether the person is physically qualified to perform the duties to be assigned...

This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Administrator agreed to submit copy of health screening and negative TB test for S6 to CCLD by POC due date.
8
9
10
11
12
13
14
Based on LPA's observation, interview and record review the Licensee did not comply with the section cited above in by having a copy of Staff (S6's) health screening and a negative TB result in their file which poses a potential health, safety and personal rights risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett FongTELEPHONE: (510) 725-7919
Lori Alexander-WashingtonTELEPHONE: (510) 285-3934

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025

LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LARKEY PARK HOME CARE
FACILITY NUMBER: 075601221
VISIT DATE: 04/09/2025
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
26
27
28
29
30
31
32
Deficiencies cleared continued
  • CCR 87463(c) 04/08/2025
  • CCR 87458(c) 04/08/2025

Deficiencies not cleared
  • CCR 87305(a)
  • CCR 87411(f)

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 11:20 AM LPA observed Resident (R1) still located in Room #5. Per facility sketch Room #5 is designated as a Staff Room.

  • At 11:50 AM, LPA observed no access to detached garage. Keys were not available.

The following deficiencies were observed (see LIC 809D) and 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.
  • Civil Penalties of $1000.00 assessed today.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5