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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 155801220
Report Date: 04/17/2024
Date Signed: 04/17/2024 05:06:47 PM


Document Has Been Signed on 04/17/2024 05:06 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MERCIE'S HOME #3FACILITY NUMBER:
155801220
ADMINISTRATOR:MERCEDES PENAREJOFACILITY TYPE:
740
ADDRESS:5808 CARISSA AVENUETELEPHONE:
(661) 861-9211
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:4CENSUS: 4DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Staff Marilou Bernardo
Pending Administrator, Adam		TIME COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced annual inspection visit. LPA Williams met with Staff Marilou Bernardo Pending Administrator, Adam and discussed the purpose of the visits. Four residents were present.

LPA Williams toured the facility with Staff.

Facility tour began in the front yard. The yard and pathways were clean and free of obstruction. Upon, entrance to the facility, LPA Williams observed required facility postings on the wall.

The kitchen was clean and in good repair. Knives and sharps were observed locked and inaccessible to residents.. There were 2 days of perishable and 7 days of non-perishable food supplies.

Dining room and living room was clean and had seating available for all residents. Facility temperature reflected 75 degrees Fahrenheit.

LPA observed 4 bedrooms. Bedrooms had space for clients and were clean and in good repair. Rooms had mattress, linens, dresser, night stand, and working lights. Room were personalized by clients.

Two bathroom for client use, was clean and in good repair. Shower, sink, and toilet all had running water.

Tour finished in the backyard. There was seating and shaded area available for client use.

Medications and chemicals were observed locked and inaccessible to clients.

*Continued on LIC 809C*
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
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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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 #3
FACILITY NUMBER: 155801220
VISIT DATE: 04/17/2024
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Smoke detectors, carbon monoxide, and fire extinguishers were present and operational.

First aid kit was present and had all required items.

LPA reviewed 3 files and 3 employee files. All files employee files had all required documents requested by the LPA. 1 of 4 resident files did not have record of their Tuberculosis screening. Additionally, the LPA did not locate a Pre-Admission appraisal in 4 of 4 resident files.

Deficiencies are being cited on the attached LIC 809D page.

Plan of correction was reviewed and discussed.

An exit interview was conducted and a copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/17/2024 05:06 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, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MERCIE'S HOME #3
FACILITY NUMBER: 155801220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

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 4 out of 4 total count persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Agreed to complete pre-appraisals and submit copies to the Department by POC due date of 4/26/2024.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above in 1 out of 4 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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2
3
4
Agreed to contact Resident 2 physician and schedule an appointment. Licensee will contact the Department by POC due date 4/18/2024, with the scheduled appointment 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: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4