247202428-3-22-2021-24-AS-LCAA-BZCTW2-20210322150448

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 247202428
Report Date: 01/22/2021
Date Signed: 03/22/2021 03:04:51 PM

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:	PARK MERCED		FACILITY NUMBER:	247202428
ADMINISTRATOR:	ELINA MOILANEN		FACILITY TYPE:	740
ADDRESS:	3050 M STREET		TELEPHONE:	(209) 722-3944
CITY:	MERCED	STATE: CA	ZIP CODE:	95348
CAPACITY:	125	CENSUS: 47	DATE:	01/22/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	James Nordman, Vice President of Operations		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Lady Cabrera contacted James Nordman, Vice President of Operations by phone due to COVID-19 and pre-cautionary measures.

On 1/19/2021, Community Care Licensing received the Unusual Incident/Injury Report that occurred on 12/06/2020. The purpose of the phone call is to follow-up and to obtain additional information.

LPA requested the following documents and records by 1/25/2021:

1. Resident’s Admission Agreement

2. LIC602A

3. All staff and all resident’s rooster

An exit interview was conducted with the Administrator and a copy of this report was provided via email.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

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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