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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 155801220
Report Date: 04/29/2022
Date Signed: 04/29/2022 03:05:23 PM

Document Has Been Signed on 04/29/2022 03:05 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MERCIE'S HOME #3FACILITY NUMBER:
155801220
ADMINISTRATOR:MERCEDES PENAREJOFACILITY TYPE:
740
ADDRESS:5808 CARISSA AVENUETELEPHONE:
(661) 861-9211
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Adam Tauchen, Office Manager
Gerald De Claro, Co-Administrator		TIME COMPLETED:
03:20 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 4/29/22 at 11:20 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. Administrator was not available. Office Manager Adam Tauchen and Co-Administrator Gerald De Claro arrived a short time later.

LPA conducted tour with staff and did not observed any obstructions. No fire issues observed. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and each resident has their own room. LPA checked residents’ medications. Cleaning and PPE supplies were checked. Resident files have updated emergency contact information.

The following deficiencies were observed:
1. Staff on duty, S1, was found to be fingerprint cleared, but not associated to the facility and has been working since 5/12/21.
2. First hall bathroom hot water tested at 100.4 degrees F and the second hall bathroom hot water tested at 102.5 degrees F.
3. Supply of nonperishable foods of minimum of one week was not maintained in the facility.

The following updated forms to be sent to CCL within 2 weeks: LIC500, LIC400, LIC402, LIC610D (new revision)

Continue to LIC809C.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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
Document Has Been Signed on 04/29/2022 03:05 PM - It Cannot Be Edited


Created By: Malia Thao On 04/29/2022 at 01:53 PM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MERCIE'S HOME #3
FACILITY NUMBER: 155801220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, records review, the licensee did not comply with the section cited above. Staff on duty, S1, was found to be fingerprint cleared, but not associated to the facility and has been working since 5/12/21, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
1
2
3
4
Co-Administrator completed and submitted LIC9182 for S1. POC cleared during the inspection.
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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/29/2022 03:05 PM - It Cannot Be Edited


Created By: Malia Thao On 04/29/2022 at 01:53 PM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MERCIE'S HOME #3
FACILITY NUMBER: 155801220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. First hall bathroom hot water tested at 100.4 degrees F and the second hall bathroom hot water tested at 102.5 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2022
Plan of Correction
1
2
3
4
Co-Administrator will submit proof of hot water in first and second hall bathroom to be within range of 105-120 degrees F to CCL by POC due date.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Supply of nonperishable foods of minimum of one week was not maintained in the facility, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 05/02/2022
Plan of Correction
1
2
3
4
Co-Administrator will submit proof of receipt for purchase of nonperishable foods to CCL by POC due date.
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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MERCIE'S HOME #3
FACILITY NUMBER: 155801220
VISIT DATE: 04/29/2022
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
26
27
28
29
30
31
32
Continued from LIC809.

Deficiencies are being cited based on LPA's observations and interview in accordance with the California Code of Regulations, Title 22, see LIC809D. A civil penalty is being assessed in the amount of $100 per day, for a maximum of 5 days, for a total of $500. See LIC421BG for more details.

Exit interview conducted. A copy of this report and appeal rights were given to Office Manager Adam Tauchen, whose signature confirms receipt of this report.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4