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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600255
Report Date: 07/25/2023
Date Signed: 07/25/2023 03:05:16 PM

Document Has Been Signed on 07/25/2023 03:05 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:MERCY RETIREMENT & CARE CENTERFACILITY NUMBER:
015600255
ADMINISTRATOR:ADRIAN JOHN CRUZ, JR.FACILITY TYPE:
741
ADDRESS:3431 FOOTHILL BOULEVARDTELEPHONE:
(510) 534-8540
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY: 160CENSUS: 77DATE:
07/25/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Josie Davis, Asst. Executive DirectorTIME COMPLETED:
03:10 PM
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On 7/25/23 at 1:35 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to continue the 1-Year Annual Required inspection started on 3/16/23. LPA met with Asst. Executive Director, Josie Davis and explained the purpose of the visit.

During the visit LPA interviewed 5 staff, inspected the medication room, medication cart and reviewed a sample of 3 resident's medications.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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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