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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600114
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:48:51 PM


Document Has Been Signed on 09/11/2024 03:48 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 BRUNO RO, 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:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Luong "Jack" Ly, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On September 11, 2024, Licensing Program Analysts(LPAs) John Calandra and Yi Sam Jian arrived at the facility at 12:05 PM to complete the Annual 1-year required Inspection. LPAs Calandra and Jian were greeted by Luong "Jack" Ly, Administrator and explained the purpose of the visit.

LPAs toured the physical plant. This is a 2 story building with 8 bedrooms and 3 bathrooms, backyard, kitchen, living room, dining room, garage/office, and laundry room. No accessible bodies of water or hazards were observed. The facility's fire extinguishers were last checked on 6/18/2024 and were fully charged. Bedrooms were sufficiently lit and had the required furniture. The facility's first aid kit had the required items. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility was maintained at a comfortable temperature.

All sharp objects, poisons, chemicals, and soap were locked and in-accessible to persons in care. One can of body soap and handwashing soap were removed and locked in the presence of the LPAs.

LPAs reviewed 5 resident files and 6 staff files. All staff files were observed to be complete but 4 out of 5 resident files were missing the Annual Needs and Services Plan.

A Technical Violation was provided for not having 4 resident Annual Needs and Services Plans.

A Type A Violation was provided for restricting a resident's movement while in bed.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

An Exit interview was conducted. This report was reviewed with Luong "Jack" Ly, Administrator and a copy of the report along with Appeal Rights left at the facility.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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 3


Document Has Been Signed on 09/11/2024 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MERCED RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 385600114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(1)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87608(a)(1): Postural Supports: Based on observation, the licensee did not comply with the section cited above in 1 out of 1 residents of which the facility had placed a foam pad to restrict the resident's movement, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Administrator/Licensee to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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