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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601219
Report Date: 01/19/2023
Date Signed: 01/19/2023 04:03:46 PM


Document Has Been Signed on 01/19/2023 04:03 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
E BAY DELTA AC/SC, 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: 15DATE:
01/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Geraldyn Ricasata, Back-up AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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On 1/19/2023 at 3:30 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct a case management regarding the civil penalty issued on 12/20/2022 was not generated in FAS correctly. LPA met with the back-up Administrator Geraldyn Ricasata, and disclosed the purpose of the visit.

LPA re-issued LIC809D and a correct civil penalty $500 on today's day.

Exit interview conducted with back-up Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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 2


Document Has Been Signed on 01/19/2023 04:03 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: LAKE MERRITT CARE HOME
FACILITY NUMBER: 015601219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
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Deficiency was cleared on 12/21/2022.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 4 staff member has not been associated with facility since was hired on 12/13/22 which poses an immediate health, safety or personal rights risk to persons in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2