079201632-1-28-2026-15-AS-TSGN-DQRS68-20260128123532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201632
Report Date: 01/28/2026
Date Signed: 01/28/2026 12:39:01 PM

Document Has Been Signed on 01/28/2026 12:39 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:	A&B LOVING CARE HOME		FACILITY NUMBER:	079201632
ADMINISTRATOR/ DIRECTOR:	BALANCIO, MILDRED		FACILITY TYPE:	740
ADDRESS:	729 MARJORAM DRIVE		TELEPHONE:	(415) 624-9109
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY: 6		CENSUS: 0	DATE:	01/28/2026
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Ireneo Alban.Licensee/ Mildred Balancio Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

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On 01/28/2026 at 10:00 AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived announced to conduct a Pre-licensing Inspection. LPA met with Ireneo Alban, Licensee and Mildred Balancio, Administrator. LPA explained the purpose of visit. The facility fire clearance was approved for six (6) non ambulatory residents.

LPA toured the facility with Licensee/Administrator including but not limited to the residents' bedrooms, bathrooms, kitchen, common areas, garage, and outdoor area. LPA observed facility has sufficient lighting throughout the facility. There were no bodies of water observed. The facility consists of five (5) bedrooms one (1) bedroom occupied by staff, and three (3) bathrooms. LPA observed non-skid mats and grab bars in showers. There is activity materials observed in the living room. First-aid kit was observed to be complete.

Smoke detectors and carbon monoxide were operational. Fire extinguisher was purchased on 10/24/2025. Emergency/Disaster plans/contact information, personal rights were observed posted in common areas.

Continue on LIC809C.....

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: A&B LOVING CARE HOME	FACILITY NUMBER: 079201632
	VISIT DATE: 01/28/2026

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Continued from LIC809

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1.)LPA observed facility does not have bedspreads for all six (6) beds.

2.)LPA observed facility does not have chest of drawers for all six (6) residents

3.)LPA observed facility does not have grabs bars for toilets in two (2) of three (3) residents’ bathrooms.

4.)LPA observed facility does not have 7-day of nonperishables and 2 days of perishable foods.

5.)LPA observed facility does not have telephone service.

6.)LPA observed facility does not have internet service.

7.)LPA observed facility does not have signal system.

8.)LPA observed facility does not have a complete ramp in the back yard. construction is still being done on ramp.

9.)LPA observed facility does not have passageways in backyard free from obstruction.

10.) LPA observed facility does not have storage space for gardening tools, equipment and paints.

Licensee/Applicant will submit proof of corrections to CCLD on/before 02/03/2026.

COMP III will be conducted during next visit. Exit interview conducted and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC809 (FAS) - (06/04)

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