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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 155801220
Report Date: 04/27/2023
Date Signed: 04/28/2023 01:03:41 PM

Document Has Been Signed on 04/28/2023 01:03 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: 3DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Gerald Declaro, AdministratorTIME COMPLETED:
01:52 PM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator Gerald Declaro and discussed the purpose of the visit. All residents were in programs.

LPA Williams toured the facility with the Administrator.

The living room was clean, good repair, and had seating available for all residents.

The bathroom is near the front entrance. It was clean, in good repair, and had non slip mats and grab bars available for use.

Three of the four bedrooms are occupied. All bedrooms had bed, required linens, chair, dresser, night stand, and lamp.

LPA Williams observed extra linens and hygiene in the hallway closet.

The dining room accommodated all residents. Two days of perishable food and seven days of non perishable food was observed. Refrigerator temperature reflected approximately 30 degrees Fahrenheit (F) and water temperature reflected approximately 107 degrees F.

The backyard had a covered area for residents and was free of obstruction. There is no pool on the premises.

*Continued on LIC 809-C*
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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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: 04/27/2023
NARRATIVE
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Smoke detector, carbon monoxide, and fire extinguisher were present and operational.

First aid kit was present with all required items.

Chemicals and medications were locked and inaccessible to residents.

LPA Williams reviewed three resident files. Between the three residents the most recent input date for Centrally Stored Medication logs was August 2022. Additioanlly, Resident 3 admission agreement had a date of 5/12/2021. However, there was no signature from the resident, authorized representative or facility representative.

Based on today's inspection, a deficiency were cited in the areas evaluated and listed on the LIC 809D page, according to California Code of Regulations Title 22, Division 6. Plan of Correction was developed and reviewed with the Administrator.

An exit interview was conducted and a copy of this report and appeal rights will be provided via e-mail.


SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2023 01:03 PM - It Cannot Be Edited


Created By: Darius Williams On 04/27/2023 at 01:35 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: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2023
Section Cited
CCR
87465(h)(6)

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(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement was not met evident by:
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Administrator agreed to complete April 2023 Centrally Stored Logs with complete and accurate information for 3 residents. Administrator will submit logs to the Department by POC due date of 5/5/2023
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Based on LPA record review, 3 of 3 residents did not have a completed log between 8/2022 and 3/2023, which poses a potential health and safety risk to person's in care.
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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.
SUPERVISOR'S NAME:Serigy Pidgirny
LICENSING EVALUATOR NAME:Darius Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
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