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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200614
Report Date: 11/26/2024
Date Signed: 11/27/2024 08:52:50 AM

Document Has Been Signed on 11/27/2024 08:52 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:ARLINGTON CARE HOMEFACILITY NUMBER:
079200614
ADMINISTRATOR/
DIRECTOR:		CINDY HONGYAN CHENFACILITY TYPE:
740
ADDRESS:2545 ARLINGTON BLVDTELEPHONE:
(510) 316-6687
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Benita De Guzman, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:00 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 11/26/2024 around 09:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced for a required annual inspection. LPA met with Benita De Guzman, Caregiver (S1) and explained the purpose of the visit. The facility’s fire clearance was approved for eight (8) non-ambulatory residents; four (4) may be Hospice approved.

Upon arrival, LPA observed one (1) staff attending to the residents and serving breakfast, and several residents visiting in the common area watching television. LPA toured the facility with S1. The areas included but were not limited to the common areas, dining room, bathrooms, kitchen, laundry room, office and backyard. The front yard and passageways were free of obstruction. A comfortable temperature was maintained at 72 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature in the shared restroom was measured at 113.6 degrees (F). The shared restroom had paper towels, soap and garbage cans; all areas were safe and sanitary. PPE, sanitizer, and paper goods remain sufficient. There was a 2-day supply of perishable foods and a 7-day supply of non-perishable foods.

...continued on LIC9099C.
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Lisha HolmesTELEPHONE: 510-286-4201
DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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 3
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: 11/26/2024
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 LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and last serviced 12/29/23. Emergency Disaster Plan is updated; safety drills and training are rotational. LPA reviewed four (4) staff files, and five (5) resident files that were complete.

-Around 09:37 AM, LPA witnessed 3 unlocked scissors on the cabinet mixed with pens and pencils in wooden holder; S1 corrected during visit.
-Around 09:46 AM, LPA observed lysol cleaner, a can of air freshener, and clorox wipes unlocked in the hallway closet; S1 corrected during visit.
-Around 09:50 AM, LPA observed R1's oxygen tank stored without it's stand in room #1; S1 corrected during visit.
-Around 10:07 AM, there was a body of water present near the garage in the backyard where cement (approximately 10x10 ft. opening) had been poured due to the construction and rain but is inaccessible to residents.

The following forms are to be updated and submitted to CCLD by 12/04/24:
-Resident Roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Reviewed)
-Administrator's Standard Certificate

Deficiencies are being cited on the attached LIC 809D. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided to OP and ED.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/27/2024 08:52 AM - 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: 11/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above by not storing R1's oxygen tank on a secured stand in room #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
1
2
3
4
Staff corrected deficiency during visit and to perform in-service training for all staff regarding the regulation by the POC date. Provide proof to CCLD.
Section Cited
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 and interviews, the licensee did not comply with the section cited above by not locking scissors and disinfectants which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
1
2
3
4
Staff corrected deficiency during visit and to perform in-service training for all staff regarding the regulation by the POC date. Provide proof to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Lisha HolmesTELEPHONE: 510-286-4201

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024

LIC809 (FAS) - (06/04)
Page: 3 of 3