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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201466
Report Date: 10/01/2025
Date Signed: 10/01/2025 05:30:54 PM

Document Has Been Signed on 10/01/2025 05:30 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:ALONDRA CARE HOME 3FACILITY NUMBER:
019201466
ADMINISTRATOR/
DIRECTOR:		AYE, THINNFACILITY TYPE:
740
ADDRESS:27765 DECATURTELEPHONE:
(510) 391-1257
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 5DATE:
10/01/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Thinn Aye/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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While at the facility conducting inspection with Thinn Aye, administrator (ADM), for investigation of a complaint (Control # 15-AS-20250825103605), Licensing Program Analyst (LPA) Delmundo observed dividing walls and 2 beds in the garage.

After granting of fire clearance by fire department on 1/22/25, and before granting of license, pre-licensing inspection was conducted by LPA on 3/13/25. LPA observed rooms with permanent walls installed in the garage. LPA reached out to fire marshal, and ADM had the rooms demolished. LPA reached out to fire marshal again regarding the dividing walls installed in the garage. Per fire marshal, the dividing walls are not allowed and that the demolition of the walls on the garage and the explanation of not using it as habitable space was conveyed prior.The garage can only be used if permitted and constructed per code, otherwise, it should remain a garage.

On this day, 10/01/25, LPA learned and observed resident (R1) has 5 and 1 scratches/wounds on the lower right arm and left arm respectively caused by the dog in the facility. ADM stated the incident happened 2 days ago. On this same day, 10/01/25, the same dog came inside the facility and kept jumping on LPA.

LPA also observed resident (R2) with two half bed rails on one side of the R2's bed, and R2 is not on hospice.

.......continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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)
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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: ALONDRA CARE HOME 3
FACILITY NUMBER: 019201466
VISIT DATE: 10/01/2025
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Deficiencies, plan and proof of correction and civil penalty were discussed with ADM.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/01/2025 05:30 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/01/2025 at 11:35 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: ALONDRA CARE HOME 3
FACILITY NUMBER: 019201466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2025
Section Cited
CCR
87203

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
-This is not met as evidenced by:
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Administrator had the dividing walls and mattresses removed.
In addition, administrator to remove the captain beds and dividing walls removed from the garage. Pictures to be submitted by 10/02/25.
A $1,000.00 civil penalty is assessed.
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-Based on observation, the licensee did not comply with the section above in have dividing walls in the garage and beds which pose an immediate risks to the safety risk to persons in care.
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Type A
10/02/2025
Section Cited
HSC1569.269(a)(5)

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ยง1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
-This is not met as evidenced by:
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Corrected.
Administrator removed the dog while LPA was at the facility.
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-Based on observation and interviews, the licensee did not comply with the section above when R1 sustained wounds/scratches caused by the dog in the facility.
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2025 05:30 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/01/2025 at 03:52 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: ALONDRA CARE HOME 3
FACILITY NUMBER: 019201466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2025
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Supports: (a) Postural supports may be used under the following conditions.(5)..(B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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Corrected.
Administrator removed the other half bed rail.
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-Based observation, the licensee did not comply with the section above in having full bedrails in R2's bed which poses a potential personal rights risk to person 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2025


LIC809 (FAS) - (06/04)
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