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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601051
Report Date: 03/13/2026
Date Signed: 03/13/2026 02:06:37 PM

Document Has Been Signed on 03/13/2026 02:06 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LA CONCEPCION RESIDENTIAL CARE HOMEFACILITY NUMBER:
015601051
ADMINISTRATOR/
DIRECTOR:		CONCEPCION, CRISTINAFACILITY TYPE:
740
ADDRESS:4419 JACINTO DRTELEPHONE:
(510) 574-0755
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 4DATE:
03/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Cristina Concepcion, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 03/13/2026 at 9:00 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Cristina Concepcion and explained the purpose of the visit. Administrator certificate is current.

LPA toured the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are occupied by the residents and 2 bedroom is occupied by staff. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 03/31/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 09/15/2025.

At 9:53 AM, LPA reviewed 4 residents records. At 10:21 AM, LPA reviewed 3 staff records and 2 of 3 have current first aid training and 2 of 3 are associated with the facility. At 12:00 PM, LPA reviewed a sample of resident’s medications.

Continue to LIC809-C…
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2026
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 12
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 12
Document Has Been Signed on 03/13/2026 02:06 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/13/2026 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a screw locking one of the sides gate, a screwdriver locking the other gate, and the physical plant of the facility not matching the approved facility sketch which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/14/2026
Plan of Correction
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Administrator removed the screw and screwdriver from both gates. By 03/20/2026, Administrator agrees to send an updated facility sketch and LIC200 to request for fire inspection for the staff room. $500 of immediate civil penalty is assessed.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having knife and scissors unlocked in the kitchen, Tylenol, Robitussin, Hydrocortisone Cream, Scissors, etc in R3's room, and disinfectants in the garage which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/14/2026
Plan of Correction
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By POC date, the Administrator agrees to lock the items and send 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-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 03/13/2026 02:06 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/13/2026 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having S2 associated with the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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By POC date, the Administrator agrees to associate S2 and send proof to CCLD.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The residents' files are incomplete such as their Appraisal Needs and Services Plan (LIC625), Identification and Emergency Information (LIC601), and Physician Report (LIC602A) for R3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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By POC date, the Administrator agrees to complete all the residents' records and send 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-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 03/13/2026 02:06 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/13/2026 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having fire drills conducted since September 15, 2025 which poses a potential safety risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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By POC date, the Administrator agrees to self certify the regulation and conducted a fire drill. Proof of correction will be sent to CCLD.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a doctor's order for R1, R2, and R4 half bed rail which poses a potential health and safety risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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By POC date, the Administrator agrees to obtain a doctors' order for R1, R2, and R4 for their half bed rail.
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-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/13/2026 02:06 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/13/2026 at 12:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having the staff records incomplete. S1 is missing First Aid Certification, S2 and S3 are missing Health Screening, TB Test, and CPR certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2026
Plan of Correction
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By POC date, the Administrator will obtain first aid for S1 and health screening,TB test, and CPR for S2 and S3. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87465(a)(4)
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having a doctor’s order for the Melatonin and a discontinued order for sodium, docusate sodium, smartrx, blood sugar monitoring, etc. for R4 which poses a potential safety risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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By POC date, the Administrator agrees to obtain a doctor’s order and discontinued order for the medications and send 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-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
Page: 8 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601051
VISIT DATE: 03/13/2026
NARRATIVE
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Continued from LIC809…

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/27/2026:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:15 AM, LPA observed knife and scissors unlocked in the kitchen. At 9:22 AM, LPA observed Tylenol, Robitussin, Hydrocortisone Cream, Scissors, etc in R3's room. At 9:30 AM, LPA observed the garage unlocked with disinfectants.

At 9:36 AM, LPA observed that one of the side gates is locked with a screw and the other side gate is locked with a screwdriver. At 9:45 AM, record review and observation revealed that the physical plant does not match the approved sketch on file.

At 10:59 AM, LPA observed that the residents' files are incomplete such as their Appraisal Needs and Services Plan (LIC625, Identification and Emergency Information (LIC601), and Physician Report (LIC602A) for R3.

At 11:13 AM, LPA observed that S2 is not associated with the facility.

At 11:19 AM, LPA observed that the staff records are incomplete. S1 is missing First Aid Certification, S2 and S3 are missing Health Screening and TB Test.

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC809 (FAS) - (06/04)
Page: 11 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LA CONCEPCION RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601051
VISIT DATE: 03/13/2026
NARRATIVE
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Continued from LIC809-C...

At 11:44 AM, LPA observed that R1, R2, and R4 have half bed rails without a doctor's order.

At 12:05 PM, record review revealed that for R1 there is no discontinued order for the Melatonin and doctor’s order for sodium, docusate sodium, smartrx, blood sugar monitoring, etc.

At 12:26 PM, record review revealed that the facility has not conducted a fire drill since September 15, 2025.

The Facility was 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.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC809 (FAS) - (06/04)
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