371881474-9-15-2023-18-AS-CGOH-CVPPMH-20230915112623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881474
Report Date: 09/15/2023
Date Signed: 09/15/2023 11:26:33 AM

Document Has Been Signed on 09/15/2023 11:26 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MERCY VILLA		FACILITY NUMBER:	371881474
ADMINISTRATOR:	DEGUZMAN, MA MEVYL		FACILITY TYPE:	740
ADDRESS:	651 ALDER DRIVE		TELEPHONE:	(619) 817-6568
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY:	6	CENSUS: 4	DATE:	09/15/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Administrator Mevyl Deguzman		TIME COMPLETED:	11:26 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 9:53 a.m. to conduct an announced pre-licensing visit. LPA met the Administrator Mevyl Deguzman at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) non-ambulatory and 1 bedridden resident, with 4 non-ambulatory residents in care. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: The facility temperature read at 75 degrees. The facility consists of 5 resident bedrooms, and 3.5 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with tv, lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 110.1 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The facility has a gated pool, that is covered and free from water. The pool is kept locked. The medications are stored in a locked cabinet near the kitchen and inaccessible to residents. There is a current fire clearance for the facility, smoke and carbon monoxide detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings. Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, client rights, and admissions agreement. (Continued on LIC809-C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MERCY VILLA	FACILITY NUMBER: 371881474
	VISIT DATE: 09/15/2023

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(Continued from LIC809)

Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has a medication logbook, the facility documents the resident’s medication and is in compliance with physician’s orders and regulations.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill completed 07/01/23. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Administrator Mevyl Deguzman and a copy of this report was printed Signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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