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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201011
Report Date: 06/29/2024
Date Signed: 06/30/2024 04:38:38 PM

Document Has Been Signed on 06/30/2024 04:38 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MERCIE'S HOMEFACILITY NUMBER:
157201011
ADMINISTRATOR/
DIRECTOR:		TAUCHEN, ADAMFACILITY TYPE:
735
ADDRESS:6000 POSO COURTTELEPHONE:
(661) 861-8805
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 5DATE:
06/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:10 PM
MET WITH:Admin Support staff, Gerald De ClaroTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Admin Support staff, Gerald De Claro. There are currently 6 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 107 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA observed a a broken dresser in residents bedroom, and a broken kitchen cabinet drawer. The facility does not have a current qualified Administrator. Client 1's Needs and Services (IPP) is outdated.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Admin Support staff, Gerald De Claro, and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2024
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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Document Has Been Signed on 06/30/2024 04:38 PM - It Cannot Be Edited


Created By: Sarah Hurt On 06/29/2024 at 06:44 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: 06/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.2(a)
80068.2 Needs and Services Plan

(a) The licensee shall complete a Needs and Services Plan for each client as required in Sections 81068.2, 82068.2, 82568.2, 84068.2, or 85068.2.

(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:

(1) The needs appraisal or IPP is not more than one year old.


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 Resident 1's IPP is outdated, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
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.Admin support staff Gerald De Claro agrees to provide current IPP for Resident 1 by 07/13/2024 POC date.
Type B
Section Cited
CCR
80064(a)


(a)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 record review, the licensee did not comply with the section cited above as based on records review the facility does not have a current Administrator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
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Admin support staff Gerald De Claro agrees to provide information on current Administrator by 07/13/2024 POC 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:Brenda Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/30/2024 04:38 PM - It Cannot Be Edited


Created By: Sarah Hurt On 06/29/2024 at 06:48 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: 06/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

80087 Buildings and Grounds



(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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Based on observation, the licensee did not comply with the section cited above in LPA observed one resident bottom dresser drawer to be broken, and one kitchen drawer to be broken, which poses a potential, health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
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Admin support staff Gerald agrees to repair broken dresser, and kitchen drawer by 07/13/2024 POC 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:Brenda Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2024


LIC809 (FAS) - (06/04)
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