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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601219
Report Date: 12/17/2020
Date Signed: 12/17/2020 03:56:35 PM

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:LAKE MERRITT CARE HOMEFACILITY NUMBER:
015601219
ADMINISTRATOR:MARIA V. MILAREFACILITY TYPE:
740
ADDRESS:576 VALLE VISTA AVENUETELEPHONE:
(510) 832-0442
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:15CENSUS: 14DATE:
12/17/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Irish SerranoTIME COMPLETED:
02:00 PM
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On December 17, 2020, Licensing Program Analyst (LPA) Leslie Ibo
conducted a Case Management Health with Administrator, Irish Serrano, in relation to
the death report that was submitted 12/15/2020. LPA explained that due to Shelter in Place
Order and directive from management to telework, inspection will be done via Zoom. During the tele-visit

Based on the death report R1 was crossing Grand Ave. (Oakland Ca.) near Safeway on 12/10/2020 and was fatally struck by a passing vehicle.
Based on the interview with Administrator on 12/10/2020 around 4:55pm R1 went out from the facility and did not tell any of the staff & also did not sign out from the sign in and out log book of the facility, facility also has video when R1 went out the facility on 12/10/2020. Administrator mentioned to LPA that R1 used to always go to Safeway almost every day and comes back to the facility. On December 10,2020, R2 witnessed R1 went out the facility, R2 asked R1 where he is going and R1 told R2 that he is going to Safeway.

LPA will need to conduct follow up visit, LPA requested for Physician’s report, Police report, admission agreement and documents about the R1’s history while at the facility.

Exit interview conducted. Appeal Rights and a copy of this report emailed
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020
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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