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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600114
Report Date: 01/03/2022
Date Signed: 01/03/2022 05:15:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MERCED RESIDENTIAL CARE FACILITYFACILITY NUMBER:
385600114
ADMINISTRATOR:JOYCE, LEEFACILITY TYPE:
740
ADDRESS:259 BROAD STREETTELEPHONE:
(415) 585-6112
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 14DATE:
01/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Luong LyTIME COMPLETED:
05:30 PM
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LPA Audrey Jeung toured facility and grounds of this 2-level home, consisting of 4 client bedrooms on the ground floor and 4 client bedrooms on the upper floor. On the 2nd floor, there are 2 shared bathrooms, kitchen and living room, and on the ground floor, there is a shared bathroom, sitting area, and garage office. There are stairs leading down to fenced backyard. Facility is connected to 257 Broad St., licensed as Merced Two Residential Care Facility--license #385600181. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 13 residents present, and 5 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Tommy Lee and Luong Ly are certified RCFE administrators (x 4/23 and 5/22) that oversee facility operations.

The following updated form is requested to be submitted to CCLD BY 1/10/22:

• LIC 309 Administrative Organization
• Proof of current liability insurance


No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. See Technical Advisory Notes for additional information.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
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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