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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200750
Report Date: 12/21/2023
Date Signed: 12/21/2023 10:09:55 AM


Document Has Been Signed on 12/21/2023 10:09 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:
12/21/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Teresita CollongTIME COMPLETED:
10:20 AM
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On this day, LPA arrived unannounced to conduct POC visit from citation issued on 12/11/2023. LPA met with staff Teresita Collong.

LPA observed facility has installed temporary video cameras in all four exits of the facility. Administrator is able to view/access all cameras by phone. A permanent video camera will be installed in the next few days per Administrator.

The deficiency is cleared and a copy of this report was provided to Collong.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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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