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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200364
Report Date: 09/27/2021
Date Signed: 09/27/2021 04:35:20 PM

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 HOME - NORMANDY LANEFACILITY NUMBER:
079200364
ADMINISTRATOR:NICANOR M. REYESFACILITY TYPE:
740
ADDRESS:245 NORMANDY LANETELEPHONE:
(925) 478-8881
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 0DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Nicanor ReyesTIME COMPLETED:
05:00 PM
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On 09/27/21 at 2:45PM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Licensee who said that the last of the residents died only a few days earlier. The Licensee had completed a mitigation plan dated 03/23/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with the Licensee as well as COVID-19 infection control practices.

Because there were no residents at present and the Licensee said that he was "taking a break" from this work, there was no COVID-19 signage nor the visitor's log and infection control station he once had near the front entrance.

The LPA inspected the facility inside and outside and found it to be in order.

No deficiencies cited during this visit.

Exit interview conducted and a copy of this report provided to administrator.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
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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