<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201447
Report Date: 10/03/2025
Date Signed: 10/03/2025 10:17:55 AM

Document Has Been Signed on 10/03/2025 10:17 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MERISOL CARE HOMEFACILITY NUMBER:
019201447
ADMINISTRATOR/
DIRECTOR:		BACANI, SOLEDADFACILITY TYPE:
740
ADDRESS:4102 PLEIADES PLACETELEPHONE:
(510) 431-3832
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
10/03/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Teresita Collong, Direct Care Staff TIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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 10/03/2025 at 9:00 AM, Licensing Program Analysts (LPAs) K. Nguyen and P.Manalo and arrived unannounced to conduct case management legal/Non-compliance visit and met with Direct Care Staff, Teresita Collong and explained the purpose of the visit. The Administrator was unavailable to come.

While at the facility, LPA observed the following deficiencies:

  • During the visit, LPAs observed that Resident 1 (R1) who is bedridden per Physician's Report and is staying in an approved non-ambulatory room. The facility has an approved one bedridden fire clearance for Room #2 only. However, R1 is occupying Room #3. Interview with Direct Care Staff, Teresita, stated that the R1 was discharged from hospice on September 09, 2025. However, interview with Staff 1 (S1) revealed that R1 is unable to move side to side.
  • Administrator not present for a sufficient enough hours.
  • The auditory signal in the kitchen/living room sliding door was not working.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Civil penalty of $750 for fire clearance violation is issued today.

Exit interview was conducted and Appeal Rights was provided to Collong.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2025
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 4
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)
Page: 2 of 4
Document Has Been Signed on 10/03/2025 10:17 AM - It Cannot Be Edited


Created By: Kelly Nguyen On 10/03/2025 at 09:15 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERISOL CARE HOME
FACILITY NUMBER: 019201447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2025
Section Cited
CCR
87202(a)

1
2
3
4
5
6
7
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department...

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agrees to notify the fire department of the bedridden resident within 24 hours and send proof to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation and interview, the licensee did not comply with the section cited above by having R1 in RM 3 that is not approved for bedridden. R1 physician report dated back in March 2025 showed that R1 is bedridden which poses a immediate safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/03/2025 10:17 AM - It Cannot Be Edited


Created By: Kelly Nguyen On 10/03/2025 at 09:37 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERISOL CARE HOME
FACILITY NUMBER: 019201447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2025
Section Cited
CCR
87405(a)

1
2
3
4
5
6
7
(a) All facilities shall have a qualified and currently certified administrator…The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agrees that the facility will hire a new full time qualified administrator per regulation requirements and send proof to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by not being present at the facility for sufficient hours which poses a safety risk to persons in care.
8
9
10
11
12
13
14
Type B
10/17/2025
Section Cited
CCR87705(d)

1
2
3
4
5
6
7
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agrees to send an audio video 3 times a day every day for the next two weeks and send proof to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by having the auditory device in the kichen/living room sliding door off which posed a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4