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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002914
Report Date: 08/22/2022
Date Signed: 08/22/2022 03:24:48 PM


Document Has Been Signed on 08/22/2022 03:24 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:MERYL'S LAKESIDE CARE HOMEFACILITY NUMBER:
315002914
ADMINISTRATOR:ABELARDO, BERYLFACILITY TYPE:
740
ADDRESS:4531 WATERSTONE DRTELEPHONE:
(916) 899-5406
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 4DATE:
08/22/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Beryl AbelardoTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Talwinder Bains met with applicant, Beryl Abelardo , to conduct an announced Pre- Licensing visit. LPA followed current Covid precautions- self screened, hand sanitized and surgical mask worn. LPA was screened upon arrival. This application is a change in ownership(CHOW) . This address is currently licensed as Greening's Care Home II Facility # 315002155. Applicant holds a current administrator certificate (# 6054363740 with expiration date 11/24/2023). Facility currently has 4 residents.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. Facility inspection is done for these areas but not limited to five (5) bedrooms , two (2) bathrooms, staff break area, office area,kitchen, common area, garage, outside area and laundry area . Bathrooms and bedrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home are operational. Fire extinguisher is ready for emergency use. Facility was approved for 6 non-ambulatory residents.

Component III was waived because applicant is administrator for another RCEF.

LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components.

Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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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