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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881298
Report Date: 05/02/2022
Date Signed: 05/02/2022 03:50:22 PM

Document Has Been Signed on 05/02/2022 03:50 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MERCY OF GOD LLCFACILITY NUMBER:
331881298
ADMINISTRATOR:DODO-WILLIAMS, TAYEFACILITY TYPE:
735
ADDRESS:13671 REGIS DRIVETELEPHONE:
(909) 996-2400
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 0DATE:
05/02/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Licensee- Taye WilliamsTIME COMPLETED:
04:00 PM
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On 05/02/2022 Licensing Program Analyst (LPA) Janira Arreola conducted an announced visit for the purpose of a pre-licensing inspection. LPA met with Licensee, Taye Dodo-Williams and was granted entry. LPA took a tour of the interior and exterior of the home. The home will be licensed for a total capacity of (4) ambulatory residents, ages 18 through 59.

LPA was informed that no firearms or ammunition will be kept at facility. LPA observed the home as follows: The home is single story 4 bedroom and 2 bathroom home with an attached garage. Each bathroom had paper towels, and soap. LPA advised licensee to obtain a trash bin with a lid and hand washing posters in both bathrooms. All 4 bedrooms have a night stand, reading lamp, bed, and closet space. LPA advised Licensee to obtain trash bins with lids for all 4 bedrooms that will be used as isolation rooms. LPA observed enough personal hygiene supplies including deodorant, shampoo, tooth brushes, toothpaste and body wash. The dining area has 4 chairs, and the outdoor seating area also has 4 chairs. LPA tested the hot water temperature which was 119 degree Fahrenheit. The kitchen has a 7 day supply of non-perishable food and enough plates, cups, and silverware for 4 residents. LPA will give the Licensee a technical violation for not have a 2 day supply of perishable foods.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MERCY OF GOD LLC
FACILITY NUMBER: 331881298
VISIT DATE: 05/02/2022
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LPA observed a working phone for residents use. LPA observed the home to have ample supply of extra towels and linens for resident’s use. Medications will be locked and stored in a file cabinet next to the kitchen and cleaning supplies will be kept in locked laundry room in locked cabinet. LPA observed a complete first aid kit and manual within medication cabinet. LPA observed sliding doors in backyard and Licensee stated that they would be disposed of by the end of the day.

LPA reviewed Component III with Licensee, Taye Dodo-Williams and this report. A copy of this report was give to Licensee Taye Dodo-Williams.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC809 (FAS) - (06/04)
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