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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600255
Report Date: 03/16/2023
Date Signed: 03/16/2023 05:36:34 PM


Document Has Been Signed on 03/16/2023 05:36 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: 73DATE:
03/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:John Cruz, Jr., Executive DirectorTIME COMPLETED:
05:45 PM
NARRATIVE
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On 3/16/2023 at 9:15 AM, Licensing Program Analysts (LPAs) G. Clark and G. Luk arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, John Cruz, Jr. and Resident Care Director, Elvira Suciu and explained the purpose of the visit. The facility’s fire clearance was approved for 120 non-ambulatory and 40 ambulatory residents.

LPAs toured the facility with Elvira including but not limited to 5 residents' apartments, bathrooms, multiple activity rooms, kitchen, common area, and outdoor area. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 degrees F. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 112.7 and 107.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Facility order food supplies twice a week. Centrally stored medications are locked and inaccessible to residents in care. At 12:40 PM, LPAs reviewed 5 residents records. At 1:30 PM, LPA reviewed 5 staff records and 5 of 5 were fingerprint cleared and associated to the facility.

LPAs will return at a later time to complete the annual inspection.

At 10:40 AM, LPAs observed a water fountain about 15 ft x 2 ft x 2 ft in the courtyard outside the facility accessible to residents.

At 1:00 PM, LPAs observed R5 tested positive for TB on 2021 and chest x-ray was not on file.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 03/16/2023 05:36 PM - It Cannot Be Edited

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: MERCY RETIREMENT & CARE CENTER
FACILITY NUMBER: 015600255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a water fountain accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Facility stopped the water fountain during inspection. Executive Director has agreed to create a written plan to address the water fountain prior to activating the fountain and submit the plan to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/16/2023 05:36 PM - It Cannot Be Edited

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: MERCY RETIREMENT & CARE CENTER
FACILITY NUMBER: 015600255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by R5 testing positive for TB and not having a chest x-ray on file which poses a potential health and safety risk to persons in care.
POC Due Date: 04/04/2023
Plan of Correction
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Facility has agreed to obtain chest x-ray for R5 and submit a copy to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
LIC809 (FAS) - (06/04)
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