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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201087
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:10:30 PM


Document Has Been Signed on 09/15/2022 02:10 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 #5FACILITY NUMBER:
157201087
ADMINISTRATOR:PENAREJO, MERCEDESFACILITY TYPE:
740
ADDRESS:812 SESNON STREETTELEPHONE:
(661) 323-0462
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:6CENSUS: 4DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Gerald De Claro, Administrator
Lynell Rattler, House Manager		TIME COMPLETED:
02:25 PM
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On 9/15/22 at 12:15 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. There was no one at the facility. LPA called Administrator (ADM) Gerald De Claro and explained reason for inspection. ADM and House Manager (HM) Lynell Rattler arrived about 30 minutes later.

LPA toured the facility with ADM and HM. 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. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Administrator certification is valid.

No deficiencies cited during this inspection.

The following forms are to be submitted to CCL within 2 weeks:

LIC400, LIC402, LIC500, LIC610E, Proof of liability insurance

Exit interview conducted. A copy of this report was given to Administrator Gerald De Claro, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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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