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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601219
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:23:13 PM


Document Has Been Signed on 07/28/2023 02:23 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
OAKLAND ASC, 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:
07/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Renaldo Casildo, Care StaffTIME COMPLETED:
02:35 PM
NARRATIVE
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On 7/28/2023 at 1:35 PM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to conduct a Case Management visit. AGPA met with Care Staff Renaldo Casildo and explained the purpose of the visit. AGPA spoke to Administrator, Iris Serrano over the phone. Administrator is not available to meet with AGPA.

In March of 2023, CCLD obtained information revealing that S1 was convicted by the District Attorney's Office of 3 misdemeanors from an investigation conducted by Department of Labor (DIR). In addition, CCLD obtained a record of Lake Merritt CHI, LLC on Franchise Tax Board (FTB) with suspended status as of 9/2/2014. S1 did not report to neither of these issues to CCLD.

The following 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.

Administrator authorized Care Staff, Renaldo Casildo to sign report.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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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Document Has Been Signed on 07/28/2023 02:23 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: LAKE MERRITT CARE HOME
FACILITY NUMBER: 015601219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/1569
Section Cited
CCR
1569.58(a)(2)

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1569.58(a)(2) Persons prohibited from being a licensee...
(a) The department may prohibit any person from being a licensee.. or being an administrator....who has done any of the following:(2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.
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Licensee/Administrator has appointed a temporary Administrator to oversee facility.

DEFICIENCY CLEARED DURING VISIT
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Based on DA records obtained, the Licensee did not comply with the regulation cited above. Licensee engaged in conduct inimical to health, welfare and safety of residents in care by continuing to work around residents after licensee reached a plea agreement to 3 misdemeanors which poses a potential health and safety risk to persons in care.
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Type B
08/18/2023
Section Cited
CCR87405(d)(5)

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877405(d)(5) ADMINISTRATOR - QUALIFICATIONS AND DUTIES
(d)The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(5)Good character and a continuing reputation of personal integrity.
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By POC date, Licensee/Administrator will submit proof of resolution with FTB to CCLD. In addition, Licensee/Administrator will review regulation 87405(d)(5) ADMINISTRATOR - QUALIFICATIONS AND DUTIES and submit a self-certification of understanding to CCLD.
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This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above by not reporting to CCLD of 3 misdemeanors by DIR and suspension status with FTB which poses a potential health and safety 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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