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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150408795
Report Date: 08/05/2022
Date Signed: 08/05/2022 11:38:56 AM


Document Has Been Signed on 08/05/2022 11:38 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MERCIE'S HOME #1FACILITY NUMBER:
150408795
ADMINISTRATOR:PENAREJO, MERCEDESFACILITY TYPE:
735
ADDRESS:3555 BELLE TERRACETELEPHONE:
(661) 833-9827
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:6CENSUS: 4DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joseph Washington, Administrator
Rick Vicente, House Manager		TIME COMPLETED:
11:50 AM
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 8/5/22 at 9:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA called Licensee Mercie Penarejo and advised reason for inspection. Administrator (ADM) Joseph Washington and House Manager (HM) Rick Vicente arrived about 30 minutes later. No residents or staff present during the inspection.

LPA conducted tour with ADM and HM, and did not observe any obstructions. No fire issues observed. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked. LPA checked residents’ medications. Cleaning and PPE supplies were checked.

The following deficiencies were observed:
1. LPA did not observe one week supply of nonperishable foods.
2. Living room sliding screen door observed with an approximately 8 inch cut through the screen mesh.

The following update forms to be sent to CCL within 2 weeks:
LIC500, LIC400, LIC402, LIC610D

Deficiencies are being cited based on LPA's observations in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report and appeal rights were given to Administrator Joseph Washington, whose signature confirms receipt of this report. Plan of correction was made with Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
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 08/05/2022 11:38 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, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MERCIE'S HOME #1
FACILITY NUMBER: 150408795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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. Living room sliding screen door observed with an approximately 8 inch cut through the middle of the screen mesh, which poses a potential health risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
1
2
3
4
Administrator will submit proof of living room sliding screen door mesh replaced to CCL by POC due date.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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. LPA did not observe one week supply of nonperishable foods, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
1
2
3
4
Administrator will submit proof of emergency food kit and additional nonperishable food in the pantry to CCL by POC due date.

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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2