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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440577
Report Date: 02/07/2024
Date Signed: 02/13/2024 10:10:51 AM

Document Has Been Signed on 02/13/2024 10:10 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MERCY CARE HOMEFACILITY NUMBER:
071440577
ADMINISTRATOR:FLORENTINA BUDOMOFACILITY TYPE:
740
ADDRESS:272 EL DIVISADEROAVE.TELEPHONE:
(925) 935-1785
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 4DATE:
02/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Licensee / Administrator Florentino "Tina" BudomoTIME COMPLETED:
05:30 PM
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On 02/07/2024 at 2:40 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a required annual inspection. LPA explained the purpose of the visit to Licensee / Administrator Florentino "Tina" Budomo.

The LPA inspected facility inside and out. LPA reviewed files of 4 residents and 5 staff members. There were at least 7 days of nonperishable and 2 days of perishable foods. Temperature in the facility at 3:36 PM was measured at 71.2 degrees in the living room. Fire extinguisher was fully charged and serviced on 3/27/2023. Carbon monoxide and smoke detectors operational. Administrator is on site a minimum of 20 hours a week to oversee proper business operation.

No citations issued during inspection.

Exit interview conducted with Licensee for whom a copy of this report was provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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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