385600349-7-16-2024-14-AS-MHAN-D78SRN-20240716140638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600349
Report Date: 07/16/2024
Date Signed: 07/16/2024 09:04:32 PM

Document Has Been Signed on 07/16/2024 09:04 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 THREE RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	385600349
ADMINISTRATOR:	JOYCE, LEE		FACILITY TYPE:	740
ADDRESS:	1420 HAMPSHIRE STREET		TELEPHONE:	(415) 285-7660
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94110
CAPACITY:	33	CENSUS: 33	DATE:	07/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator, Joyce Lee		TIME COMPLETED:	02:15 PM

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	On July 16, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with administrator, Joyce Lee and explained the purpose of today's visit. Current census is 33 residents. A tour of the facility was conducted with the administrator. This is a single story facility and the ground level is for storage purpose and laundry. Living room, dining area, kitchen and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents. Resident bathrooms are Jack and Jill style and shower rooms are located in the hallway. The indoor and outdoor passageways were free of obstruction. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Facility is equipped with audible alarm by the exit doors. Call system is installed in resident rooms and bathrooms. Comfortable temperature is maintained and lighting is sufficient for comfort. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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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Document Has Been Signed on 07/16/2024 09:04 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 THREE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 385600349
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed 1 out of 5 residents with a diagnosis of Dementia did not have a recent updated medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/23/2024
	Plan of Correction
1 2 3 4	The administrator will obtain a copy of an updated medical assessment for resident and will submit a copy to CCL by 7/23/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MERCED THREE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 385600349
	VISIT DATE: 07/16/2024

NARRATIVE

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Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care.

Hot water temperature in the bathrooms were measured at 108-111 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 6/18/2024.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (4) staff files was conducted and noted on the LIC 859.

LPA requested for a copy of the Liability Insurance to be submitted by 7/17/2024.

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

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/16/2024 09:04 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 THREE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 385600349
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

This requirement is not met as evidenced by: 87608 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.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 5 out of 5 residents have quarter/half bedrails on the beds without a physician's order which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/23/2024
	Plan of Correction
1 2 3 4	The administrator will provide a copy of the physician's order for the device that is being used and provide a copy to CCL by 7/23/2024.

Type B

Section Cited

CCR

87506(a)

This requirement is not met as evidenced by: 87506 Resident Records (a) The licensee shall ensure that a separate, complete,
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in LPA observed 5 out of 5 resident appraisal needs/services plan were not signed by the facility representative, the resident and/or the RP which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/23/2024
	Plan of Correction
1 2 3 4	The administrator will provide a copy of the completed resident appraisal/needs and services plan to CCL by 7/23/2024.

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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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