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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508864
Report Date: 11/05/2025
Date Signed: 11/05/2025 06:10:00 PM

Document Has Been Signed on 11/05/2025 06:10 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:FHAR - MERCED DRIVE HOMEFACILITY NUMBER:
410508864
ADMINISTRATOR/
DIRECTOR:		SURDEL, PHILFACILITY TYPE:
735
ADDRESS:270 MERCED DRIVETELEPHONE:
(650) 403-0403
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 5DATE:
11/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Phil SurdelTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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On 11/5/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to deliver the investigation outcome of an incident that was reported by the facility. LPA met with administrator and explained the purpose of the visit.

On 9/9/2025, the facility reported that at around 7:30AM, staff #1(S1) heard the auditory device on the downstairs door went off but S1 did not physically check the alarm because S1 thought the alarm was triggered by resident #1 (R1) who went to the garage. A few moments later, (S1) discovered R1 was missing and reported it to the House Manager who was on her way to the facility.

The House Manager looked for R1 around the facility and found R1 walking around at the local elementary school accompanied by the school nurse. The house manager brought R1 back to the facility.

On 9/10/2025, LPA conducted a case management visit to obtain additional information concerning the incident and during the visit, LPA observed the auditory devices on the sliding door in the kitchen, the door to the garage and the door to the back were malfunctioned ( the facility was cited on the same day, see LIC 809 and LIC 809 D).

LPA interviewed (S1) who stated that on 9/9/2025 at 7:20AM - 7:25 AM, she was working by herself and when she noticed R1 was not around the facility, she started searching the entire facility and observed the latch on the gate by the garage was open so she immediate reported it to the house manager. However, she did not know exactly which exit R1 took to leave the facility as she was caring for the other residents.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: FHAR - MERCED DRIVE HOME
FACILITY NUMBER: 410508864
VISIT DATE: 11/05/2025
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After the investigation, deficiency is cite as on the day of the incident, S1 was not aware that R1 left the facility unassisted as she providing care to the other residents. In addition, on 9/10/2025, LPA observed 3 out of 4 auditory devices on the doors were malfunctioned.

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

AN IMMEDIATE CIVIL PENALTY OF $500 WAS ASSESSED TODAY AS FACILITY DID NOT ENSURE SUFFICIENT STAFFING TO PROVIDE CARE AND SUPERVISION TO RESIDENTS IN CARE.

This report is reviewed and discussed with the administrator and a copy of the report is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 06:10 PM - It Cannot Be Edited


Created By: Murial Han On 11/05/2025 at 09:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: FHAR - MERCED DRIVE HOME
FACILITY NUMBER: 410508864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2025
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the client's needs.
This is requirement is not met as
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The Licensee/administrator will develop a plan to ensure facility has sufficient staff to care and supervise residents at all times to prevent incident from happening again and will provide a copy of an updated LIC500. The plan shall
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evidenced by based on observation, interview and record review, on 9/9/2025, R1 left the facility unassisted while S1 was providing morning care to another resident which poses an immediate health and safety risk to residents in care.
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include staff training. The Licensee/administrator will provide a copy of the plan of correction and a LIC 500 to CCL by 11/6/2025.

An Immediate Civil Penalty in the amount of $500 is being assessed today.

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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
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