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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200750
Report Date: 12/19/2023
Date Signed: 12/19/2023 11:37:34 AM


Document Has Been Signed on 12/19/2023 11:37 AM - 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:
12/19/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Soledad BacaniTIME COMPLETED:
11:55 AM
NARRATIVE
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On this day at around 10:30 am, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management-health checks in connection with complaint #15-AS-20231218143948. LPA met with Administrator Soledad Bacani.

During the visit, LPA inspected the facility inside and out including but not limited to resident rooms, common areas, bathroom and backyard. Hot water measured at 115 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. LPA checked alarms installed on each exit door and observed auditory device in Room 4 is not functional. One resident was observed sitting on the recliner in the living area watching TV/napping. The other two residents are in their respective rooms who both state they are doing okay.

In the back and side yards, LPA observed construction materials such as planks of wood, chair, dresser, gravel and different tools.

Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted and 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: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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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Document Has Been Signed on 12/19/2023 11:37 AM - 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: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2023
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 requirement is not met as evidenced by:
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Administrator replaced the battery during visit.Deficiency is cleared
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LPA observed auditory device installed in Room 4 is not functional which poses an immediate threat to the health and safety of clients under care.
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Type B
12/29/2023
Section Cited
CCR87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator states will conduct general cleaning of the facility and will notify LPA. LPA will need to come back to verify completion.
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This requirement is not met as evidenced by:
Based on observation, wood planks, gravel, construction tools, dresser, chairs etc were observed in the side/back yards and kitchen windows with black mold which poses a potential risk to health and safety of clients under care.
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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: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2