<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200099
Report Date: 01/25/2022
Date Signed: 01/25/2022 12:14:11 PM

Document Has Been Signed on 01/25/2022 12:14 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: 2DATE:
01/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Mercedita Lara/LicenseeTIME COMPLETED:
12:30 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
While at the facility for a complaint (Control # 15-AS-20220118105814) and waiting for Mercedita Lara (licensee) to arrive, Licensing Program Analyst (LPA) Delmundo observed the following in the backyard: ladder and soiled/wet dining chairs on the patio/deck; pails of paint and grout; old plastic roofing; dried twigs/tree branches on the ground; broken shopping cart; soiled Christmas decorations

Deficiency is cited from Title 22 Calfornia Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Geraldine Lara (administrator) over the phone in the presence of Mercedita Lara.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Mercedita Lara.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
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 2
Document Has Been Signed on 01/25/2022 12:14 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/25/2022 at 11:52 AM
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: 01/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2022
Section Cited
CCR
80087(a)

1
2
3
4
5
6
7
80087 Buildings 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:
1
2
3
4
5
6
7
Licensee stated she'll have the yard cleaned.

In addition, licensee to do in-service training.

Pictures and copy of in-service training to be submitted by 2/01/2022.
8
9
10
11
12
13
14
-Based on observation, the licensee did not comply with the section above. LPA observed the following in the backyard: ladder soiled/wet dining chairs on the patio/deck; pails of paint and grout; old plastic roofing; dried twigs/tree branches on the ground; broken shopping cart; soiled Christmas decorations which pose potential risks to person in care,
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2