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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200099
Report Date: 06/29/2022
Date Signed: 06/30/2022 03:00:51 PM

Document Has Been Signed on 06/30/2022 03:00 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:GERALDINE LARAFACILITY TYPE:
735
ADDRESS:26768 LAUDERDALE AVENUETELEPHONE:
(510) 785-8997
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 3DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Mercedita Lara/Licensee-Co-administratorTIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Minda Navarro, Gloria Arches and Arthur Romel Rodriquez, and informed the purpose of visit. LPA spoke over the phone with Mercedita Lara, licensee/co-administrator, who arrived at around 2:30 pm.

Facility has an approved LIC808 Mitigation Plan on file.

LPA toured the facility inside out with Arthur Romel Rodriquez. LPA inspected the living room, dining area, kitchen, common and ensuite bathrooms, bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

Visitor's temperature and symptom checks are done at entrance. Residents and staff are screened for COVID-19 symptoms and temperature checked and recorded daily. Facility keeps record of proof of vaccination of residents and staff, and antigen test kits are readily available. LPA observed trash bins with foot pedal operated lids in the bathrooms. Supplies of PPEs were checked.

Fire extinguisher checked and observed fully charge.

LPA observed the following:
1. No Covid-19 signages/posters in the living room.
2, Storage in the backyard converted into staff living quarter.
3. Unlocked Glucosamine and medications in the storage converted into staff living quarter.
4. Staff medications in one of unlocked bedrooms.

......continued next page
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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 7
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: LADY OF MERCED CARE HOME, INC.
FACILITY NUMBER: 019200099
VISIT DATE: 06/29/2022
NARRATIVE
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5. Cans of Acetone, Roundup weed and grass killer, paint thinner in the backyard.
6. Tree branch cutter and anti-corrosion/anti-freeze agent in the common area adjacent to the dining room.

Staff Minda Navarro who stated she's been working since March 2022 is not fingerprint cleared and associated to this facility. Two staff, Maria Concepcion Carlos and Rogelio Tabeta, who according to Mercedita Lara, have worked 2 weekends this month of June are also not fingerprint cleared and associated.

Administrator to submit copies of the following updated documents by July 13, 2022:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

LPA reminded that new Infection Control Plan should be submitted by June 30. 2022.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Civil penalties are assessed. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with Mercedita Lara.

Exit interview conducted. Appeals Rights, LIC421BC, LIC421IM, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 06/30/2022 03:00 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/29/2022 at 05:54 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: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 staff which poses an immediate safety risks to persons in care. Three staff not fingerprint cleared and associated.

Total of $1,300.00 civil penalty is assessed.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee stated she'll have all the 3 staff fingerprinted and will not allow to work in the facility until cleared and associated. Proof to be submitted by POC date.
Type A
Section Cited
CCR
80020(a)

80020 Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by converting the storage into staff living quarter and not obtaining permit and fire clearance.

A $500.00 civil penalty is assessed.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee stated she'll have the beds removed and put back the storage to it's original use as storage. Picture to be submitted by 8/30/2022.
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: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/30/2022 03:00 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/29/2022 at 06:05 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: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which pose an immediate health and safety risks to persons in care. LPA observed the following: unlocked Acetone, paint thinner, weed/grass killer, tree branch cutter, anti-corrosion/anti-freeze agent, staff medications
POC Due Date: 06/30/2022
Plan of Correction
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Staff locked the items while LPA is at the facility.
Licensee to do in-service training and submit proof by 6/30/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022


LIC809 (FAS) - (06/04)
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