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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600181
Report Date: 07/12/2024
Date Signed: 07/12/2024 10:40:30 AM


Document Has Been Signed on 07/12/2024 10:40 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:MERCED TWO RESIDENTIAL CARE FACILITYFACILITY NUMBER:
385600181
ADMINISTRATOR:JOYCE LEEFACILITY TYPE:
740
ADDRESS:257 BROAD STREETTELEPHONE:
(415) 585-6112
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 14DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Luong LiTIME COMPLETED:
11:00 AM
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On 7/12/24 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Co-Administrator Luong Li. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen area. The indoor and outdoor passageways were free of obstruction. LPA observed some residents were in the living room watching tv. While touring the facility it was observed that the room temperature was at 69 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floor. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Facility has a chair lift. Emergency drills are logged and done every quarter.

Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA received the following documents LIC308, LIC500, Liability Insurance, Copy of Deed & LIC610.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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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