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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601219
Report Date: 09/16/2024
Date Signed: 09/16/2024 12:03:20 PM


Document Has Been Signed on 09/16/2024 12:03 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: 14DATE:
09/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Renaldo Casildo, CaregiverTIME COMPLETED:
12:20 PM
NARRATIVE
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On 09/16/2024 at 10:00 AM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit to follow-up on the accusation document that was provided to the facility. LPA met with Caregiver, Renaldo Casildo and explained the purpose of the visit.

LPA toured facility with Caregiver, Renaldo Casildo, and observed the facility posted written notice regarding the accusation in an area behind a desktop monitor. LPA also spoke with four (4) residents to confirm if they have received written notice, only two (2) out of the four (4) residents confirmed that they did read the notice. However, individual notices were not provided to each resident, their responsible parties and the long term care ombudsman.

During the visit LPA obtained a copy of the notice that was posted in the facility, a copy of resident signatures on the notice and a copy of the resident registry list.

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.

Civil penalty assessed today at $300.00 ($100 X 3 days) and will continue to accrue until deficiency is cleared.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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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Document Has Been Signed on 09/16/2024 12:03 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: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2024
Section Cited
HSC
1569.38(b)

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§1569.38 Posting of licensing reports; disclosure to new residents(b)A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events:

This requirement is not met as evidenced by:
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Administrator agreed to send letters to each resident, resident's responsible parties and long term care ombudsman and send copies of letetrs to CCLD by POC date.
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Based on observation and interview the licensee did not comply with the section cited above by not sending written notifications of pending action to each resident, each residents' responsible parties and the long term care ombudsman which poses a potential health, safety and personal rights risk to persons in care. Civil penalty assessed for $300 today and accruing $100/daily until cleared.
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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) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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