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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440577
Report Date: 02/14/2023
Date Signed: 02/14/2023 01:14:40 PM


Document Has Been Signed on 02/14/2023 01:14 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:MERCY CARE HOMEFACILITY NUMBER:
071440577
ADMINISTRATOR:FLORENTINA BUDOMOFACILITY TYPE:
740
ADDRESS:272 EL DIVISADEROAVE.TELEPHONE:
(925) 935-1785
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
02/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Tina BudomoTIME COMPLETED:
01:25 PM
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On 02/14/2023 at 12:20 PM, Licensing Program Analyst (LPA) James Sampair began an unannounced required annual inspection. LPA explained the purpose of the visit to Administrator (ADM) Tina Budomo. LPA and ADM inspected the facility inside and outside.

The facility has an infection mitigation plan in place, and the Infection Preventionist is the ADM. Staff were following the latest COVID-19 infection control guidance.

There were at least 7 days of nonperishable and 2 days of perishable foods. Hot water and facility room temperatures maintained at comfortable temperatures. Fire extinguisher was fully charged and serviced within the past year. Carbon monoxide and smoke detectors operational. Administrator is on site a minimum of 20 hours a week to oversee proper business operation.

No citations issued during inspection.

Administrator to send updated copies of these documents to CCL on or before 02/21/2023:
  1. LIC500 - Personnel Report
  2. LIC308 - Designation of Financial Responsibility
  3. LIC610D - Emergency/Disaster Plan
  4. Evidence of sufficient Liability Insurance

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
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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