157201087-10-10-2022-24-AS-MHON-CKAN55-20221017100857

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157201087
Report Date: 10/10/2022
Date Signed: 10/10/2022 09:02:55 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2022 and conducted by Evaluator Malia Thao

COMPLAINT CONTROL NUMBER: 24-AS-20220713134030

FACILITY NAME:	MERCIE'S HOME #5		FACILITY NUMBER:	157201087
ADMINISTRATOR:	PENAREJO, MERCEDES		FACILITY TYPE:	740
ADDRESS:	812 SESNON STREET		TELEPHONE:	(661) 323-0462
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93309
CAPACITY:	6	CENSUS:	DATE:	10/10/2022
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Gerald De Claro, Administrator		TIME COMPLETED:	09:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect resulting in hospitalization.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 10/10/22 at 8:35 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to deliver the findings for a complaint. LPA called Administrator (ADM) Gerald De Claro and explained reason for inspection. ADM arrived a short time later. No staff or residents present during the inspection.

During the course of the investigation, the Department conducted interviews and records review that revealed that R1’s admission to the hospital was unrelated to neglect. Based on such, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited during this inspection.

An exit interview was conducted, and a copy of this report was left with Administrator Gerald De Claro, whose signature on this form confirms receipt of these documents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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