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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366406395
Report Date: 08/30/2023
Date Signed: 08/30/2023 10:01:09 AM

Document Has Been Signed on 08/30/2023 10:01 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:MERCYLAND HOME IIFACILITY NUMBER:
366406395
ADMINISTRATOR:NOEL ESHOFACILITY TYPE:
735
ADDRESS:6680 ROCA CIRCLETELEPHONE:
(909) 888-8876
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY: 6CENSUS: 4DATE:
08/30/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Maria Hapan - DSPTIME COMPLETED:
10:03 AM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced collateral visit to this facility in relation to complaint control number: 56-AS-20230822103713. LPA phone administrator Noel Esho of LPA's visit and findings.

During the investigation, it was discovered that day program clients who were found with bed bugs on their person and personal items reside at this home. Interview with staff confirmed that pest control treatment has been started on the home last week. During today's visit, LPA observed live bugs along a client mattress corner. This poses a potential health and safety risk to clients in care.

Refer to LIC809-D for deficiency cited. An exit interview was conducted with and a copy of this report, LIC809-D, and appeal rights were provided to facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/30/2023 10:01 AM - It Cannot Be Edited


Created By: Anna Bueno On 08/30/2023 at 08:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MERCYLAND HOME II
FACILITY NUMBER: 366406395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2023
Section Cited
CCR
80087(a)(1)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement was not met as evidenced by:
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Licensee shall conduct pest control treatment. Licensee shall provide training on how to treat and prevent bed bugs to all staff. Treatment and training shall be conducted by a licensed professional.
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Staff interviews reveal that the facility has been receiving an average of two bed bug treatments a year.
This shows that bed bugs are a reoccurring issues and poses a potential health and safety risk to clients in care.
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Licensee shall submit proof of training to the Department no later than end of POC date.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


LIC809 (FAS) - (06/04)
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