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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200750
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:42:10 PM


Document Has Been Signed on 12/11/2023 03:42 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: 3DATE:
12/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Soledad BacaniTIME COMPLETED:
04:00 PM
NARRATIVE
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On this day at around 1:45 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management-incident visit and met with Administrator Soledad Bacani. LPA explained to Administrator the purpose of the visit.

On 12/7/2023, Administrator left vm to LPA regarding Resident 2 (R2) missing from the facility. On 12/11/23, LPA made a follow up with Administrator. Administrator informed LPA that Resident 2 (R2) who had Alzheimer's Disease left the facility on 12/7/23 without staff knowledge. Administrator and staff tried to find R2 but failed. Administrator states she informed R2's family and Union City Police Department. And on 12/10/23, Administrator states R2's husband informed staff 1 (S1) that R2 passed away on 12/8/23.

During the visit, LPA obtained the following records for Resident 1 (R1):
  • Medication Administration Record (MAR)
  • Physician's Report
  • Admission Agreement
  • Appraisal Needs and Services Plan
  • Death Report
  • Incident Report


The deficiency is cited (refer to Lic 809D) from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview was conducted with Soledad. Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/11/2023 03:42 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: 12/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2023
Section Cited
CCR
87705(j)

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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirementt is not met as evidenced by:
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Administrator will install Ring video camera on all exits and submit proof to CCL.
Safety check every hour during the day; every 2 hours at night pending installation of ring camera. Once installed, every 4 hrs at night; hourly during the day safety check.

A Non Compliance Conference will be scheduled to address issues.
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R2 who has Alzheimer's Disease left the facility without staff knowledge on 12/7. Administrator & staff tried to find R2 but failed. The incident was reported to the police department and R2's family. On 12/10/23, R2's husband notified facility that R2 died on 12/8.
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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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
LIC809 (FAS) - (06/04)
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