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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200750
Report Date: 04/19/2023
Date Signed: 04/19/2023 12:19:40 PM


Document Has Been Signed on 04/19/2023 12:19 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 HOMEFACILITY NUMBER:
079200750
ADMINISTRATOR:BACANI, SOLEDADFACILITY TYPE:
740
ADDRESS:4102 PLEIADES PLACETELEPHONE:
(510) 431-3832
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
04/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Soledad BacaniTIME COMPLETED:
12:20 PM
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At around 10:45 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct case management inspection of the Additional Dwelling Unit (ADU) constructed in the backyard. LPA met with Soledad and explained purpose of visit.

LPA observed ADU has been completed. Administrator states her sister, Teresita Bacani Collong Administrator for Merisol Care and her family live in the ADU.

During the visit, LPA was not able to access ADU because it was locked. LPA also observed fence is being replaced.

LPA requested the following records from Administrator to be sent to CCL by Friday, April 21, 2023:

city approved permit for ADU, Fire Inspection, updated facility sketch, health and safety plan during construction of new fence.

A copy of this report was provided to LPA.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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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