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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200099
Report Date: 06/20/2024
Date Signed: 06/20/2024 07:03:39 PM

Document Has Been Signed on 06/20/2024 07:03 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
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:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Geraldine Lara/Administrator
and Mercedita Lara/Licensee		TIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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On this day, June 20, 2024, at 1:50 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Yolanda Rebollido. LPA also met with other staff, Arthur 'Romel' Rodriguez and Nestor Arches. LPA called and spoke over the phone with Geraldine Lara, administrator, and informed the reason for visit. Administrator arrived at around 2:00 p.m., followed by Mercedita Lara, licensee.

Administrator submitted the LIC9282 Infection Control Plan which LPA received on June 30, 2022.

LPA started the inspection with Rommel Rodriguez and continued with the administrator. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguisher was observed fully charge with tag showed serviced February 9, 2024. 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 105.5 degrees Fahrenheit. Facility conducts fire drill monthly and earthquake drill every quarter, and records showed last conducted May 21, 2024 and April 22, 2024 respectively.

LPA reviewed 5 staff and 3 residents files, and interviewed 2 staff and 2 residents. P&I money checked and compared with last recorded balance. Medications w\ere inspected and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders on file.

LPA observed the following:
-at 1:55 p.m., unlocked medication central storage.
-at 1:58 p.m., knives and scissors in unlocked kitchen drawer.
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....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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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: 06/20/2024
NARRATIVE
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Page 2

-at 2:03 p.m., fire place cover unsecured.
-at 2:07 p.m, razors and scissors in unlocked staff room
-at 2:13 p.m., shovel in the backyard.
-at 3:30 p.m., facility does not have a certified administrator; Geraldine Lara and Mercedita Lara's certificates expired.
-at 5:00 p.m., resident R1 has doctor's order for Gabapentin, 100 mg, 1 tablet daily and 300 mg 2 tablets 3x daily but facility does not have the 100 mg. R1 also has order for Lisinopril 2.5 mg filled on 1/04/24 and recorded on LIC622 Centrally Stored Medication and Destruction Record and started on 6/19/24; however, the bottle is still unopened. This medication was refilled on 6/04/24 but not recorded on LIC622 Centrally Stored Medication and Destruction Record. R1 has Atorvastin filled 1/04/24 and recorded started on 2/21/24 but the bottle is still unopened, This medication was refilled on 4/05/24 but not recorded on LIC622.

LPA received the following current/updated documents on this same day:
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. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with the administrator.

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: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/20/2024 07:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/20/2024 at 06:09 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: 06/20/2024

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 the following which poses an immediate safety and/or personal rights risks to persons in care: knives and scissors in unlocked kitchen drawer; razors and scissors in unlocked staff room; shovel in the backyard
POC Due Date: 06/21/2024
Plan of Correction
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Staff locked all the items.
In addition, administrator to do in-service training and submit proof by 6/21/24.
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

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 facility not having the Gabapentin, 100 mg which poses an immediate health and/or personal rights risks to person in care.
POC Due Date: 06/21/2024
Plan of Correction
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Administrator to check with the doctor if the medication is no longer needed and obtain discontinued order; otherwise, obtain the medication. Proof to be submitted by 6/21/24.
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: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/20/2024 07:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/20/2024 at 06:10 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: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in central storage for medications unlocked which poses an immediate health, safety and/or personal rights risks to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Staff locked the central storage,
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 6/21/24.
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: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/20/2024 07:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/20/2024 at 06:10 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: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

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 in fire place cover unsecured which poses a potential safety risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Administrator stated she'll have the fire place cover fixed. Picture to be submitted by 7/04/24.
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in not having a certified administrator which poses a potential personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee to hire a certified administrator and submit the following:
1. Signed letter stating a ceritifed administrator is hired.
2. Copies of administrator certificate, LIC500 and LIC501.
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: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/20/2024 07:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/20/2024 at 06:34 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: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 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 records review, the licensee did not comply with the section cited above in not properly recording R1 medicatiions on LIC622 which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Administrator to do the following and submit proof by 7/04/24.
1. Correct the LIC622 and submit corrected copy.
2. Hire a licensed professional to conduct training and submit proof.
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: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
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