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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600255
Report Date: 10/03/2024
Date Signed: 10/03/2024 11:23:05 AM

Document Has Been Signed on 10/03/2024 11:23 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:MERCY RETIREMENT & CARE CENTERFACILITY NUMBER:
015600255
ADMINISTRATOR/
DIRECTOR:		DAVIS, JOSEPHINE IFACILITY TYPE:
741
ADDRESS:3431 FOOTHILL BOULEVARDTELEPHONE:
(510) 534-8540
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY: 160CENSUS: 71DATE:
10/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Elvira Suciu, Resident Care DirectorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 10/03/24 at 11:15 a.m., Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to deliver amended report for the LIC9099 dated 9/12/24. LPA met with Elvira Suciu, Resident Care Director (RCH) and explained the purpose of the visit.

Amended report delivered to RCH.

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: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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