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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079200750
Report Date:
03/29/2024
Date Signed:
03/29/2024 04:48:25 PM
Document Has Been Signed on
03/29/2024 04:48 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:
3
DATE:
03/29/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:20 AM
MET WITH:
Soledad Bacani
TIME COMPLETED:
03:50 PM
NARRATIVE
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On this day at around 10:20 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Milagros Bumatay. LPA explained to Bumatay the purpose of the visit. The Administrator arrived at around 11 am.
During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, dining area, kitchen, garage and backyard. Hot water measured at 111 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. Ample supply of linen, warm blankets and towels were observed. First aid kit was observed complete. LPA observed a fire extinguisher that appeared full but did not have a tag or proof of purchase. The last fire and earthquake drill was conducted in November 2023.
Smoke detectors and carbon monoxide were tested and observed functional.
LPA reviewed three resident files and 4 staff files. All staff were observed fingerprint cleared and associated to the facility. LPA interviewed one resident and one staff. LPA reviewed medications and Medications Administration Record (MAR) with Administrator.
The following deficiencies were observed:
R1's exit door was observed blocked
backyard was observed with grass more than 1 foot tall, construction equipment, luggage, right side passageway uneven pavement, garage door needed to be opened manually
2 knives observed unlocked in the kitchen
carrots with mold in the garage
R1 uses oxygen but fire department has not been notified
missing No Smoking sign on R1's door
continuation on Lic 809C
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2024
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
11
Document Has Been Signed on
03/29/2024 04:48 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:
03/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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
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Based on observation, the licensee did not comply with the section cited above in having 2 knives unlocked and accessible in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/29/2024
Plan of Correction
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Knives were observed locked during the visit. This deficiency is cleared.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2024
LIC809
(FAS) - (06/04)
Page:
2
of
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Document Has Been Signed on
03/29/2024 04:48 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:
03/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having carrots with mold which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/29/2024
Plan of Correction
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Carrots were thrown away during the visit.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having current fire and earthquake drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/05/2024
Plan of Correction
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By POC date, proof of training will be sent to CCL.
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:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2024
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
03/29/2024 04:48 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:
03/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not notifying local fire department about a resident with oxygen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/01/2024
Plan of Correction
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The Administrator will notify fire department within 24 hours about oxygen use and submit proof to CCL by POC date.
Type B
Section Cited
CCR
87705(j)
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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having an alarm that is loud enough to alert staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/05/2024
Plan of Correction
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By POC date, Administrator will replace the alarm and send LPA proof.
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:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2024
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
03/29/2024 04:48 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:
03/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
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 in blocking exit door in R1's room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/29/2024
Plan of Correction
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The Administrator removed the blockage during visit. Deficiency cleared.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2024
LIC809
(FAS) - (06/04)
Page:
9
of
11
Document Has Been Signed on
03/29/2024 04:48 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:
03/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
873039(a)
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 in having grass more than a foot tall, construction equipment, ladder, etc in the backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/05/2024
Plan of Correction
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The Administrator will clean up the backyard and send photos to LPA by POC 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:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2024
LIC809
(FAS) - (06/04)
Page:
10
of
11
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:
03/29/2024
NARRATIVE
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Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/29/2024
LIC809
(FAS) - (06/04)
Page:
11
of
11