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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200099
Report Date: 07/28/2022
Date Signed: 07/28/2022 06:41:01 PM

Document Has Been Signed on 07/28/2022 06:41 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:
07/28/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Mercedita Lara/Licensee TIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced POC visit, and met with Mercedita Lara, license.

On June 29, 2022, LPA conducted annual required inspection and issued citation for unlocked items with proof of correction to be submitted by June 30, 2022. LPA sent text message to Mercedita Lara, licensee, and staff, Arthur Rommel Rodriguez, on June 30. 2022 regarding the submission of POC. which licensee has not submitted as of this date.

Deficiency section 80087(g) is re-cited on this day. Failure to submit the proof of correction by POC due date may result in civil penalty.

LPA spoke with Geraldine Lara, administrator, regarding the above in the presence of Mercedita Lara.

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: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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Document Has Been Signed on 07/28/2022 06:41 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/28/2022 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: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited
CCR
80087(g)

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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:
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Administrator stated she'll conduct in-service training and submit proof by 7/29/2022.
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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
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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: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022


LIC809 (FAS) - (06/04)
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