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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200099
Report Date: 06/06/2023
Date Signed: 06/06/2023 07:04:52 PM

Document Has Been Signed on 06/06/2023 07:04 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:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Arthur Rommel Rodriguez/StaffTIME COMPLETED:
07:00 PM
NARRATIVE
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On this day, June 6, 2023, LPA Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Arthur Rommel Rodriguez. LPA called and spoke over the phone with Geraldine Lara administrator. LPA also spoke with Mercedita Lara, licensee. The licensee and administrator authorized Arthur Rommel Rodriguez to be with LPA during inspection. LPA also met with other staff, Minda Navarro and Nestor Arches. The licensee arrived after about 3 hours,

Facility has an approved LIC808 Mitigation Plan. The facility submitted the LIC9282 Infection Control Plan on June 30, 2022.

LPA inspected the facility inside and out including but not limited to living room, dining area, kitchen, bedrooms, bathroom, staff room, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguisher was observed fully charge with tag showed serviced November 2, 2022. Facility has carbon monoxide and smoke detectors that were tested and observed functional. Hot water temperature in the common bathroom was tested, and measured at 110.6 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed earthquake and fire drills last conducted May 23, 2023. First aid kit inspected, and observed complete with manual. Central storage for medications and cleaning supplies were observed locked.

LPA reviewed 5 staff and 3 residents files, and interviewed 2 staff and 1 resident. P&I money checked and reconciled with records. Medications were inspected and compared with records. ,


.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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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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: 06/06/2023
NARRATIVE
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LPA observed the following:
-At 12:40 pm, hoe and shovel in the backyard.
-At 12:42 pm, pieces of wood and tiles, used toilet and bathroom sink, shutters, screen door, rusted oven toaster, broken shopping cart, pail with dried cement, rusted metal, aluminum & plastic roof, dishwasher in the backyard.
-At 3:00 pm, observed Geraldine Lara's certificate expired. LPA communicated with Geraldine and Mercedita who both indicated that Mercedita is now the administrator. Geraldine indicated Mercedita took over the administrator position beginning of this year. However, the licensee failed to notify the Department of the change.
-At 4:30 pm, resident's (R1) has 10 medications but only has doctor's order on file for 1 medication. Medications received/filled not recorded on LIC622 Centrally Stored Medication and Destruction Record.
-At 5:00 pm, resident's (R2) has 6 medications on facility's hand but only has doctor's order on file for 1 medication. Last entry on LIC622 were for medications filled on 4/04/2022.
-At 5:10 pm, resident's (R3) medications has no doctor's order on file. Medications received not recorded on LIC622,

Administrator to submit the following updated documents by June 20, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of Regulation section 80087(g) within 12 month period. 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 the licensee.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/06/2023 07:04 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/06/2023 at 05:56 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: 06/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building 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 for hoe and shovel in the backyard that are readilty accessble to residents which poses an immediate safety risk to persons in care.
This is a repeat violation within 12 months. A citation for this Regulation was issued on 7/28/22.
POC Due Date: 06/07/2023
Plan of Correction
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Staff locked the items.
In addition, the licensee to do in-service and submit copy of training topic with attendees sigantures by 6/07/23.
Type A
Section Cited
CCR
80070(b)(10)
Client Records
(b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review, , the licensee did not comply with the section cited above in 3 out of 3 residents not having complete doctor's order of medications which poses an immediate health and personal rights risks to persons in care.
POC Due Date: 06/07/2023
Plan of Correction
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Licensee to obtain doctor's orders for all the medications for 3 residents and submit copies by 6/07/23.
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: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/06/2023 07:04 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/06/2023 at 05:57 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: 06/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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. LPA observed pieces of wood and tiles, used toilet and bathroom sink, shutters, screen door, rusted oven toaster, broken shopping cart, pail with dried cement, rusted metal, aluminum & plastic roof, dishwasher in the backyard which pose a potential safety risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Licensee to have the yard cleaned, and submit pictures by 6/20/23.
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview, the licensee did not comply with the section cited above in 3 of out of 3 residents not having LIC9172 Functional Capabiliy Assessment on file which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Licensee to complete the LIC9172, and submit a self-certification by 6/20/23.
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: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/06/2023 07:04 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/06/2023 at 05:57 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: 06/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 residents not having a complete LIC622 for medications which pose a potential health and personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Licensee to have alll the medications filled/received accounted by recording on LIC622. A self-certification to be submitted by 6/20/23.
Type B
Section Cited
CCR
85061(a)(b)
85061 Reporting Requirements
(a) In addition to Section 80061, the following shall apply.
(b) The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above for not notifying the Department of the change of administrator which poses a potential personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Licensee to submit a signed letter indicating the change, and submit along with a copy of Board Resolution by 6/20/23.
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: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023


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