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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200099
Report Date: 02/12/2025
Date Signed: 02/12/2025 01:22:27 PM

Document Has Been Signed on 02/12/2025 01:22 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:LADY OF MERCED CARE HOME, INC.FACILITY NUMBER:
019200099
ADMINISTRATOR/
DIRECTOR:		GERALDINE LARAFACILITY TYPE:
735
ADDRESS:26768 LAUDERDALE AVENUETELEPHONE:
(510) 785-8997
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 3DATE:
02/12/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Geraldine Lara/Administrator
and Mercedita Lara/Licensee		TIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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On 8/22/24, Licensing Program Analyst (LPA) Delmundo called and spoke with Geraldine Lara, administrator (ADM), regarding the annual fees that were overdue and late fee assessment. ADM stated she'll pay, however, the fees remained unpaid.

On this day, 2/12/25, LPA arrived to the facility unannounced for other reason. LPA was granted entry by Praxedes Pascual, staff. LPA called and spoke over the phone with ADM and informed the reason for visit, and also discussed the annual fee and late fees that still remains unpaid, and that LPA will issue citations.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections (POCs) by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with ADM over the phone. Mercedita Lara, licensee, and ADM arrived at 12:57 pm.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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 02/12/2025 01:22 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/12/2025 at 12:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LADY OF MERCED CARE HOME, INC.
FACILITY NUMBER: 019200099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2025
Section Cited
CCR
80036(a)

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80036 LICENSING FEES
(a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1.

-This requirement is not met as evidenced by:
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Administrator stated she'll have the annual fee paid. Proof of payment to be submitted by 2/26/25.
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-Based on record review and interview, the licensee did not comply with the section above for not paying the annual fees for 2023 and 2024 ($908.00)
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Type B
02/26/2025
Section Cited
CCR80036(b)(1)(F)

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80036 Licensing Fees (b)(1) In addition to fees set forth in subdivision (a), the department shall charge the following fees:(F) A late fee that represents an additional 50 percent of the established current annual fee when any licensee fails to pay the current annual licensing fee on or before the due date
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Administrator stated she'll have the annual fee paid. Proof of payment to be submitted by 2/26/25.
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-This requirement is not met as evidenced by:

-Based on record review and interview, the licensee did not comply with the section above in not paying the late fees of $454.00 for 2023 and 2024.
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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 Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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