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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201195
Report Date: 02/03/2025
Date Signed: 02/03/2025 06:21:35 PM

Document Has Been Signed on 02/03/2025 06:21 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:SCARLET HOUSE FOR THE ELDERLYFACILITY NUMBER:
079201195
ADMINISTRATOR/
DIRECTOR:		WHITE, RACHELFACILITY TYPE:
740
ADDRESS:5111 PAUL SCARLET DRIVETELEPHONE:
(650) 580-3239
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 2DATE:
02/03/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:55 PM
MET WITH:Josielyn Ranosa, CaregiverTIME VISIT/
INSPECTION COMPLETED:
06:43 PM
NARRATIVE
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On 2/3/2025 at 4:55pm, Licensing Program Analysts (LPAs), L. Hall and C. Fowler arrived unannounced to conduct a health and safety check. LPAs met with Josielyn Ranosa, Caregiver and explained the reason for the visit. LPA L. Hall spoke with Licensee, Ace White, via telephone.

Upon arrival at 2:40pm, LPAs observed one (1) client in his bedroom and one (1) staff (S2). Two more staff (S3 and S4) arrived at 10 minuets after arrival.

During the health and safety check, LPA toured the facility including but not limited to common areas, bathrooms, bedrooms and outdoor common area. LPA observed R1 sitting in bedroom watching television and R2 sitting in recliner in bedroom reading. The facility is noted to be clean, in good repair, and clients in care appear to be safe. There is a minimum of 7-day non-perishables and 2-day perishables foods. There are no imminent health/safety concerns on today's date.

During visit LPAs observed the following deficiencies:
  • At 2:45pm, LPAs were not allowed inside the premises by S2.
  • At 3:36pm, LPA observed a ramp and two shower doors in the closet of R2's bedroom.

Continued on LIC809C.



Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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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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: SCARLET HOUSE FOR THE ELDERLY
FACILITY NUMBER: 079201195
VISIT DATE: 02/03/2025
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Continued from LIC809.
  • At 3:40pm, LPA observed a insect trap sitting on kitchen counter and in kitchen drawer.
  • At 3:48pm, LPA observed two commodes, a walker, a wheelchair, a ramp, a laundry basket, and wheel barrel in back yard.
  • At 3:48pm, LPA observed storage shed was unlocked and contained paint, a shovel, and a rake.
  • At 3:55pm, LPA observed fire extinguisher last services on 11/7/2023.


*An immediate civil penalty of $500.00 will be assessed on today's day for inspection authority*

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. 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, LIC421M, and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/03/2025 06:21 PM - It Cannot Be Edited


Created By: Laura Hall On 02/03/2025 at 05:23 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: SCARLET HOUSE FOR THE ELDERLY
FACILITY NUMBER: 079201195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2025
Section Cited
CCR
87755(a)

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 (a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise... with or without advance notice. This requirement was not met as evidence by:
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Caregiver opened the door and let LPAs inside the premise after 10 minuets. Deficiency cleared during visit.
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Based on observation the Licensee did not comply with the section cited above in letting the LPAs enter the facility, which poses a potential health and safety risk to person in care.
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*A civil penalty of $500.00 was assessed date*
Type B
02/10/2025
Section Cited
CCR87307(a)

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(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents... The following provisions shall apply: This requirement was not met as evidence by:
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Licensee agreed to remove ramp and closet doors and submit photo to CCLD by POC date.
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Based on observation and interview the Licensee did not comply with the section cited above in using R2's bedroom closet for R2's personal belongings, which poses a potential health and safety risk to 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/03/2025 06:21 PM - It Cannot Be Edited


Created By: Laura Hall On 02/03/2025 at 05:56 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: SCARLET HOUSE FOR THE ELDERLY
FACILITY NUMBER: 079201195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2025
Section Cited
CCR
87555(b)(27)

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(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
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Licensee agreed to hire an exterminator and submit invoice to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in keeping kitchen free of insects which poses a potential health and safety risk to persons in care.
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Type B
02/10/2025
Section Cited
CCR87307(d)(6)

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(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidence by:
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The Licensee agreed to remove items, lock shed, and submit photo to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having the back yard shed locked, a wheel chair, walker, commode, etc put away, which poses a potential health and safety risk to 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/03/2025 06:21 PM - It Cannot Be Edited


Created By: Laura Hall On 02/03/2025 at 06:02 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: SCARLET HOUSE FOR THE ELDERLY
FACILITY NUMBER: 079201195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2025
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 requirement was not met as evidence by:
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Licensee agreed to have fire extinguishers services and submit photo to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having the fire extinguisher serviced to meet the regulations, which poses a potential health and safety risk to 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
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