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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201119
Report Date: 11/18/2022
Date Signed: 11/18/2022 11:21:05 AM

Document Has Been Signed on 11/18/2022 11:21 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:ABOVE & BEYOND RCFE, INC.FACILITY NUMBER:
019201119
ADMINISTRATOR:LEANO, ALBERTFACILITY TYPE:
740
ADDRESS:23652 NEVADA ROADTELEPHONE:
(510) 821-0871
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
11/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Leticia Velasco, Licnesee TIME COMPLETED:
11:35 AM
NARRATIVE
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On 11/18/2022 at 09:15 am during the course of another visit, Licensing Program Analyst (LPA) J. Clancy-Czuleger discovered that the person that is listed as the administrator no longer works at the facility. The new administrator was designated in May 2022.

The licensee did not notify the Department, in writing, within thirty (30) days of administrator starting.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted With Caregiver Evan Park. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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 2
Document Has Been Signed on 11/18/2022 11:21 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 11/18/2022 at 11:02 AM
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: ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER: 019201119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2022
Section Cited
CCR
87211(g)

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Reporting Requirements.
The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator... This requirement is not met as evidence by:
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The Licensee will submit documents for change of administrator by POC date.
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Based on interview, licensee did not comply with the section cited above by not notifying the Department of administrator change which poses a potential health and safety risk to the persons in care.
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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 Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
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