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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880800
Report Date: 03/13/2023
Date Signed: 03/13/2023 01:58:01 PM

Document Has Been Signed on 03/13/2023 01:58 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MERCY CARE PLACE 1FACILITY NUMBER:
361880800
ADMINISTRATOR:ADESANYA, OLUWATOYINFACILITY TYPE:
735
ADDRESS:16492 MANCHESTER STREETTELEPHONE:
(909) 586-0790
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 2DATE:
03/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Adesanya OluwatoyinTIME COMPLETED:
02:10 PM
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 Licensing Program Analysts (LPAs) Victoria Chitgian and Michelle Echeverria conducted an unannounced visit to the facility for an annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA met with licensee Adesanya Oluwatoyin.

LPAs toured the facility inside and out. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. LPAs toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPAs toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 2/1/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the storage and laundry areas. Centrally stored medications were kept in a safe and locked cabinet. Sharps were stored in a secured area. LPAs toured the client bathrooms. LPAs measured the hot water temperature in the bathrooms and kitchen. The hot water temperature measured within required limits at 106 degrees Fahrenheit. LPAs also observed emergency supplies in the garage. The outside of the facility had a shaded area with seating for client comfort. The facility pool is locked by a gate and inaccessible to clients.
LPAs reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPAs reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.
No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the licensee Adesanya Oluwatoyin.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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