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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201011
Report Date: 06/14/2022
Date Signed: 06/14/2022 03:45:03 PM

Document Has Been Signed on 06/14/2022 03:45 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 HOMEFACILITY NUMBER:
157201011
ADMINISTRATOR:PENAREJO, MERCIEFACILITY TYPE:
735
ADDRESS:6000 POSO COURTTELEPHONE:
(661) 861-8805
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 5DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Gerald De Claro, Co-Administrator
Rosemary Dejesus, House Manager		TIME COMPLETED:
04:00 PM
NARRATIVE
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On 6/14/22 at 12:45 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. Co-Administrator Gerald De Claro and House Manager Rosemary Dejesus arrived a short time later.

LPA conducted tour with staff and did not observed 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. Two residents share a room and three residents have individual bedrooms. LPA checked residents’ medications. Cleaning and PPE supplies were checked. Food supply was observed in adequate supply.

The following deficiencies were observed:
1. Administrator does not have current Administrator certificate.
2. Facility does not have a wound care plan for R1.
3. LPA observed exterior fire exit gate with missing gate lever for latch and one kitchen drawer front is missing a side piece exposing sharp wood edges.

The following updated forms to be sent to CCL within 2 weeks:
LIC500, LIC400, LIC402, LIC610D (new revision)

Deficiencies are being cited based on LPA's observations and interview 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 Co-Administrator Gerald De Claro, whose signature confirms receipt of this report.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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 3
Document Has Been Signed on 06/14/2022 03:45 PM - It Cannot Be Edited


Created By: Malia Thao On 06/14/2022 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MERCIE'S HOME
FACILITY NUMBER: 157201011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Administrator does not have a current Administrator certification, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Administrator will submit all documents to change Administrator for the facility to CCL by POC due date.
Type A
Section Cited
CCR
80092.2(a)
Restricted Health Condition Care Plan
(a) If the licensee of an ARF chooses to care for a client with a restricted health condition, as specified in Section 80092, the licensee shall develop and maintain, as part of the Needs and Services Plan, a written Restricted Health Condition Care Plan. The plan must include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Facility does not have a wound care plan for R1, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Administrator will submit proof of a wound care plan for R1 in compliance of CCR 80092.2 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 Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/14/2022 03:45 PM - It Cannot Be Edited


Created By: Malia Thao On 06/14/2022 at 03:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MERCIE'S HOME
FACILITY NUMBER: 157201011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observations, the licensee did not comply with the section cited above. LPA observed exterior fire exit gate with missing gate lever for latch and one kitchen drawer front is missing a side piece exposing sharp wood edges, which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
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Administrator will submit proof of exterior fire exit gate lever installed and kitchen drawer front replaced or repaired to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
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