015601480-4-29-2022-15-AS-LFII-CDXVR8-20220429163932

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601480
Report Date: 04/29/2022
Date Signed: 04/29/2022 04:41:31 PM

Document Has Been Signed on 04/29/2022 04:41 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:	MERISOL CARE		FACILITY NUMBER:	015601480
ADMINISTRATOR:	TERESITA BACANI		FACILITY TYPE:	740
ADDRESS:	35002 VINCENTE CT.		TELEPHONE:	(510) 894-2326
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	6	CENSUS: 6	DATE:	04/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Collong, Teresita- Administrator		TIME COMPLETED:	04:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/29/2022 approximately 12:40pm, Licensing Program Analysts (LPAs) L. Fici and L. Hall arrived unannounced to conduct infection control inspection LPA's met with administrator Collong, Teresita and explained the purpose of the visit Upon arrival facility staff were not observed wearing masks. During the Infection Control Inspection, LPAs toured facility including but not limited to front yard, common areas, kitchen, bedroom, shared bathrooms. There is a central entry point for staff and visitors. LPAs did not observe a screening nor were they any COVID signage throughout facility. Facility's temperature is measured at 70 degrees F. Hand washing posters, soap, and paper towel were observed in bathroom. Fire extinguisher is maintained and serviced dated 3/9/2022. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. LPA's observed PPE's and facility has a mitigation plan on file. The following forms are to be updated and submitted to CCLD By 5/6/2022. - LIC500- Personnel Report - LIC308- Designation of Administrative Responsibility - LIC610E- Emergency Disaster Plan - An updated copy of Administrator certificate Continue on LIC809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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 4

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: MERISOL CARE	FACILITY NUMBER: 015601480
	VISIT DATE: 04/29/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continue on LIC809

the follow deficiencies were observed during inspection:

12:45pm- LPAs did not observe screening station.
12:55pm- Cleaning products such as, pledge, tide pods, downy, pine sole, arm & hammer detergent, Clorox, and glass cleaner were observed in garage, accessible to person(s) in care.
1:05pm- LPAs observed Resident 1 (R1) in bedroom #7 with half bed rails. There was not a doctor's order in R1's file. room.
1:10pm- LPAs observed shed/storage in back yard being used as living quarters for staff. Shed contained a bed, clothing, refrigerator, and medication being too S3.
1:15pm- LPAs observed R2 residing in bedroom number seven (7). On facility sketch, bedroom number #7 shows as staff room. Staff now resides in room #2.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 04/29/2022 04:41 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: MERISOL CARE	FACILITY NUMBER: 015601480
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(1)

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (1) Nonambulatory persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on(observation and record review, the licensee did not comply with the section cited above by R2.resident in bedroom #7 that shows on facility sketch bedroom #7 was designated for staff only. Staff now residing in bedroom #2. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2022
	Plan of Correction
1 2 3 4	Licensee agreed to submit and LIC200 and updated copy of facility sketch to CCLD by POC date for new fire clearance.

Type A

Section Cited

CCR

87705(f)(2)

87705 Care persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having detergents, disinfectants, and solutions, and cleaners inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2022
	Plan of Correction
1 2 3 4	Licensee agreed to reserve the door knobs where it's inaccessible to person in care by submitting a photo copy to CCL by POC date.

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-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/29/2022 04:41 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: MERISOL CARE	FACILITY NUMBER: 015601480
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(5)(A)

87608 Postural Support (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not having a doctors order for half bed rail for R1. Which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/06/2022
	Plan of Correction
1 2 3 4	Licensee agreed to submit a copy of a doctors order for half bed for R1 to CCL by POC date.

Type B

Section Cited

CCR

87305(a)

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not obtaining a permit for shed located in backyard using to reside staff member which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/06/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit a copy of a permit for the shed located in the backyard by POC date.

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-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4