079200750-2-17-2023-15-AS-LFII-CP629V-20230217161234

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200750
Report Date: 02/17/2023
Date Signed: 02/17/2023 04:12:46 PM

Document Has Been Signed on 02/17/2023 04:12 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:	MERISOL CARE HOME		FACILITY NUMBER:	079200750
ADMINISTRATOR:	BACANI, SOLEDAD		FACILITY TYPE:	740
ADDRESS:	4102 PLEIADES PLACE		TELEPHONE:	(510) 431-3832
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 5	DATE:	02/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Soledad, Bacani-Licensee		TIME COMPLETED:	04:20 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	On 2/17/2023, at 2:25PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by Soledad, Bacani-Licensee and explained the purpose of todays visit. During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All toxins were locked up and inaccessible to residents in care. Common areas are disinfected frequently throughout the day. Fire extinguisher was last serviced on 11/15/2022. Facilities room temperature is maintained at 70 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are functional. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care. During record review, LPA observed facility has a copy of their Infection Control Plan and Disaster Plan on file. Continue on Lic809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERISOL CARE HOME	FACILITY NUMBER: 079200750
	VISIT DATE: 02/17/2023

NARRATIVE

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Continued from Lic809

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

At 2:51PM, LPA observed ants in the kitchen cabinet on a bottle of honey.

At 2:53PM, LPA observed unlocked knives in kitchen draw accessible to residents.

At 3:18PM, LPA observed hot water temperature in common area bathroom at 135.9 Degrees F.

Exit interview conducted with Licensee, and a copy of this report provided along with appeal rights.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/17/2023 04:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERISOL CARE HOME	FACILITY NUMBER: 079200750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705(f)(1) Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not locking kitchen knives that are located in the kitchen draw which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/18/2023
	Plan of Correction
1 2 3 4	Licensee agree to lock up all knives in the kitchen away from residents in care. Deficiency cleared

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving, and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105-degree F (41 degree C) and not more than 120-degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by lowering the hot water temperature and making sure hot water is maintained and is in between 105-120 Degrees F to reflect the regulation above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/18/2023
	Plan of Correction
1 2 3 4	Licensee agreed to lower a hot water temperature and to maintain water temperature for the safety of residents and to submit a photo to CCL of the corrected hot water temperature by POC due date.

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/17/2023 04:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERISOL CARE HOME	FACILITY NUMBER: 079200750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

87555(b)(27) General Food Service Requirements: (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not making sure that the facility is free of insects, ants and other bugs located in the kitcken draw and common area bathroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2023
	Plan of Correction
1 2 3 4	Licensee agreed to make sure the facility is free from all insects, including ants and other bugs and to submit a self-certification on the above regulation to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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