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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600349
Report Date: 08/20/2021
Date Signed: 08/20/2021 03:11:29 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 THREE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
385600349
ADMINISTRATOR:JOYCE, LEEFACILITY TYPE:
740
ADDRESS:1420 HAMPSHIRE STREETTELEPHONE:
(415) 285-7660
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:33CENSUS: 24DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ping Ng and Joyce LeeTIME COMPLETED:
03:15 PM
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On 08/20/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required infection control inspection. At approximately 2:30 PM, LPA met with Facility Manager Ping Ng at the entrance of the facility. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility.

At approximately 2:35 PM, LPA met with Administrator Joyce Lee and toured the physical plant with the Facility Manager and Administrator. The physical plant is consistent with the submitted facility sketch/floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility receives meals from their sister facility. At 2:50 PM, LPA observed the facility's restrooms as clean and equipped with hand washing signage.

The clients' bedrooms were inspected and all had required lighting and furniture.
Facility is equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguishers as current. The facility's first aid kit included the required tweezers, scissors, and a thermometer. Cleaning solutions are stored and locked.

At approximately 2:55 PM, LPA completed the facility tour for Infection Control with the Administrator and Facility Manager. This report was reviewed with the Administrator and Facility Manager. No deficiencies were cited today.

Exit interview conducted with the Administrator. Due to technical difficulties, a copy of this report will be emailed to the Administrator.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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