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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200364
Report Date: 08/18/2022
Date Signed: 08/18/2022 03:05:10 PM


Document Has Been Signed on 08/18/2022 03:05 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 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:
08/18/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee Nick ReyesTIME COMPLETED:
03:30 PM
NARRATIVE
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On 8/18/22 at 1:30 PM, Licensing Program Analyst (LPA) J. Sampair conducted a facility closure visit with licensee Nick Reyes. This was a visit initiated by the licensee, with whom the LPA had spoken after receiving notification of his intention to close the facility effective 8/8/2022. This was a follow up to the previous year's annual visit on 09/27/2021, when the licensee told the LPA that the last of the residents had died only a few days earlier. With no residents, he was “taking a break" from this work.

The LPA inspected the facility and confirmed that there were no residents at the facility. Licensee Reyes surrendered his license to the LPA

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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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