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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200614
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:39:00 PM


Document Has Been Signed on 12/20/2023 03:39 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:ARLINGTON CARE HOMEFACILITY NUMBER:
079200614
ADMINISTRATOR:CINDY HONGYAN CHENFACILITY TYPE:
740
ADDRESS:2545 ARLINGTON BLVDTELEPHONE:
(510) 316-6687
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:8CENSUS: 7DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Benita Deguzman, CaregiverTIME COMPLETED:
03:50 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 12/20/2023 at 12:30pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson, conducted an unannounced 1-Year Required inspection. LPAs met with Benita Deguzman, Caregiver and explained the purpose of the visit. Administrator, Cindy Chen, arrived at 12;53pm. The Administrator holds a certificate #6019228740 expires 8/29/2024. The facility’s fire clearance was approved for eight (5) non-ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) total bedrooms, two (2) bathrooms, and one (1) office. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 72 degrees Fahrenheit. 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 117.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors/ carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/20/2022. Emergency Disaster Plan was last posted on 7/28/2023. First aid kit was observed to be complete.

Continued on LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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 5


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: ARLINGTON CARE HOME
FACILITY NUMBER: 079200614
VISIT DATE: 12/20/2023
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
Continued from LIC809.

Five (5) staff records were reviewed, and all staff have criminal record clearance. All seven (7) resident records were reviewed and none contained the appraisal needs and services plan.

LPA observed the following deficiencies:
  • At 1:00pm, LPAs observed during record review none of the resident files contained an appraisal needs and services plan.
  • At 1:48pm, LPA observed vitamins, cough medicines, and other medication in unlocked kitchen cabinet.
  • At 1:55pm, LPA observed a wrench, screwdriver, and 3 bottles of air fresher in unlocked cabinet located over washer and dryer.


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/20/2023 03:39 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: ARLINGTON CARE HOME
FACILITY NUMBER: 079200614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 in having tools and medication accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2023
Plan of Correction
1
2
3
4
Administrator locked medication and tools in cabinet to make then inaccessible to residents during visit. Deficiency cleared during visit.
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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 12/20/2023 03:39 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: ARLINGTON CARE HOME
FACILITY NUMBER: 079200614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having appraisal needs and service plans for each resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
1
2
3
4
Administrator agreed to create an appraisal needs and service plan for each resident and submit a self-certification to CCLD that it has been completed 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5