<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200750
Report Date: 08/09/2024
Date Signed: 08/09/2024 03:22:45 PM


Document Has Been Signed on 08/09/2024 03:22 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: 5DATE:
08/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Soledad BacaniTIME COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, LPA Luisa Fontanilla conducted a case management visit related to complaint #15-AS-20231218143948 and met with Soledad Bacani, Administrator. LPA explained to Bacani the purpose of the visit.

During the course of investigation, staff interviewed were aware about R1’s confusion and exit-seeking behavior. Staff interviewed state R1 would walk around the facility looking for exits saying, “I want to go home.” Staff were also aware about R1’s elopement incident from a Memory Care unit in another facility prior to placement to this facility.



Despite awareness and observing R1’s wandering behavior, R1 was able to leave the facility without staff knowledge on 12/7/2023. R1 was found deceased by the railroad tracks.

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

A copy of this report was provided to the Administrator 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: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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 2


Document Has Been Signed on 08/09/2024 03:22 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: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2024
Section Cited
CCR
87466

1
2
3
4
5
6
7
87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
1
2
3
4
5
6
7
Plans of correction (POCs) will be addressed in the NCC on 8/15/2024.
8
9
10
11
12
13
14
 When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such...
This requirement is not met as evidenced by: The facility did not provide appropriate assistance to R1 to ensure safety despite observing R1’s wandering behavior. R1 was able to leave the facility without staff knowledge and was found deceased by the railroad tracks.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2