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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006537
Report Date: 10/30/2024
Date Signed: 10/30/2024 09:34:17 AM

Document Has Been Signed on 10/30/2024 09:34 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MERCY MANOR CORPFACILITY NUMBER:
306006537
ADMINISTRATOR/
DIRECTOR:		GUILING, AISAFACILITY TYPE:
734
ADDRESS:1702 LA COLINA DRTELEPHONE:
(909) 841-6315
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 5CENSUS: DATE:
10/30/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Jessica GarciaTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analysts (LPAs) Kimberly Lyman and William Vanegas made an announced visit to conduct a pre-licensing inspection. LPAs identified themselves and discussed the purpose of the visit with Licensee Jessica Garcia. An initial application to operate an Adult Residential Facility for Persons with Special Health Needs was received by Community Care Licensing on 03/20/2024 for a capacity of five bedridden clients. Upon entry, facility appears clean, safe and sanitary. Administrator Aisa Guiling has an administrator certificate expiring on 04/28/2026.

LPAs along with Licensee toured the facility at 7:48 AM and observed the following:
Structure: Facility is a one story, 5 bedroom, 2 bathroom house with a tan exterior and a detached garage. The outside exit gate is closed, unlocked and self-latching. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Clients: Rooms will be single occupancy. All rooms are equipped with appropriate lighting, night stand and ample closet space. Linens & Hygiene Supplies: Facility has bedding and towels in supply. Bathrooms: All client bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in the hallway of the facility. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguisher is fully charged.. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has secured areas for toxins and sharps. Water Temperature: Tested and recorded between 115.3 and 118.9 degrees F. in facility bathrooms. Emergency Supplies: LPAs observed ample emergency food and water as well as a posted emergency disaster plan.. Medications, First-Aid Kit & Book: First aid kit observed contained all required items including tweezers, scissors and thermometer. LPA observed a first aid manual. Medication is stored in a locked cabinet and medication carts. Facility to use a medication administration record. CONTINUED ON LIC 809C DATED 10/30/2024
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MERCY MANOR CORP
FACILITY NUMBER: 306006537
VISIT DATE: 10/30/2024
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Client & Staff File: Records are to be stored in a secured file cabinet. Backyard: LPA observed a clean backyard with ample shaded seating for clients. Fire Clearance: Approved for five bedridden clients on 07/18/2024..

Licensee to address the following items:
  • Side gate does not close. Please repair/ replace.
Licensee to provide proof of correction by 11/13/2024.



Component III waived during the visit due to Licensee experience..







Exit interview conducted and a copy of this report will be provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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