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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601480
Report Date: 07/03/2023
Date Signed: 07/03/2023 01:50:47 PM


Document Has Been Signed on 07/03/2023 01:50 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 CAREFACILITY NUMBER:
015601480
ADMINISTRATOR:TERESITA BACANIFACILITY TYPE:
740
ADDRESS:35002 VINCENTE CT.TELEPHONE:
(510) 894-2326
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 5DATE:
07/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Teresita Collong, Administrator.TIME COMPLETED:
02:00 PM
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On 7/3/2023 starting at 10:00 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Teresita Collong, Administrator (ADM) and explained the purpose of the visit. Administrators certificate (6037999740) is valid and expires on 12/2/2023. The facility’s fire clearance was approved for all six (6) non- ambulatory residents, which one resident may be on hospice. Upon entry, LPA observed two (2) staff and three (3) residents present during inspection. At 10:35 AM, Licensee, Antonia Mari arrived to the facility and greeted LPA.

Starting at 10:18 AM, LPA toured facility with ADM including but not limited to seven (7) bedrooms, three (3) bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are private, and one staff room. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ common area bathroom was measured at 106.4 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Sharps and toxins were locked and inaccessible to residents'.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 5/9/2023. First aid kit was observed to be complete.


Continue on Lic809-C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
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


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
FACILITY NUMBER: 015601480
VISIT DATE: 07/03/2023
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Continued from Lic809

Starting At 10:57AM, LPA reviewed 3 of 3 staff records. At 11:30 AM, LPA reviewed 5 of 5 residents' record. At 12:05 PM, LPA reviewed a sample of 5 of 5 clients' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/10/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 Pages)
· Liability Insurance



No deficiencies cited during visit.










Exit interview conducted with Licensee, and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2