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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880800
Report Date: 11/01/2023
Date Signed: 11/01/2023 09:48:17 AM

Document Has Been Signed on 11/01/2023 09:48 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
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: 3DATE:
11/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Amos Akingtoye- AdministratorTIME COMPLETED:
09:54 AM
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Licensing Program Analyst, Michelle Echeverria, (LPA) arrived at Mercy Care Place 1, unannounced to conduct a Case Management Visit for health and safety. This case management visit is in response to a Special Incident Report, (SIR) submitted to the Community Care Licensing Office on 03/20/23. LPA was greeted by staff Emmanuel Bello at the front door and granted entrance. LPA introduced self and stated purpose of the visit. LPA met with Administrator, Amos Akintoye.

During today's visit, LPA conducted a health and safety check and conducted interviews with staff and client.

No deficiencies were observed during this visit. An exit interview was conducted where this report was, reviewed, discussed and then provided to Administrator Amos Akintoye.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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