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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 155801220
Report Date: 03/10/2026
Date Signed: 03/10/2026 03:12:05 PM

Document Has Been Signed on 03/10/2026 03:12 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MERCIE'S HOME #3FACILITY NUMBER:
155801220
ADMINISTRATOR/
DIRECTOR:		TAUCHEN, ADAMFACILITY TYPE:
740
ADDRESS:5808 CARISSA AVENUETELEPHONE:
(661) 861-9211
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 2DATE:
03/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Patrick DeclaroTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) J. Duarte arrived at the facility unannounced to conduct an Annual Inspection. There was no answer at the door. LPA contacted Administrator Adam Tauchen and he advised that staff will arrive shortly. Administrator Patrick Declaro and Adam Tauchen arrived shortly after and LPA was granted entry into the facility. Administrator stated that both residents were at day program.

The facility was observed to be at a temperature of 73 degrees F, clean with no passageway obstructions LPA observed the exterior of the house paint is peeling off. The living room has sufficient seating for residents. The kitchen was toured and LPA observed a two-day supply of perishable and seven-day non-perishable food. The facility stores sharps in a locked kitchen cabinet. Medication along with the first aid kit are locked in a kitchen cabinet as well. A fire extinguisher was observed in the kitchen, with a service date of 09/24/2025. LPA observed patch work is needed in the dining room walls and the hallway entrance walls and baseboards. Administrator advised that walls get damaged with walkers.

All bedrooms were toured and observed to have the required furniture and adequate lighting. Bathrooms were observed operational, with non-skid strips and grabbed bars observed for the showers and toilets. The ceiling to the bathroom near the entrance of the house has not been completely painted. The hot water to both restrooms measured at 106 degrees F.

The facility has a dryer and washer in the utility room. Chemicals and detergent were observed locked in a laundry room cabinet. The kitchen door that leads to the laundry room has another door that leads to the patio. The laundry room door that leads to the patio was observed to have a latch at the top to secure the door closed. The facility has a freezer in the garage with an additional food supply. The sprinkler system was inspected on 12/05/25. Outside of the facility was toured and observed to be free of debris. The facility has a gazebo in the backyard with seating available. LPA observed the gate on the west side of the residence is broken.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2026
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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Document Has Been Signed on 03/10/2026 03:12 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 03/10/2026 at 01:06 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: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(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 or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the kitchen door that leads to the laundry room has another door that leads to the patio. The laundry room door that leads to the patio was observed to have a latch at the top to secure the door closed. Administrator Adam Tauchen stated that staff advised that although the door is locked, it is able to be opened with a push, so the latch was put in place, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
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Administrator immediately removed the latch to allow the door to be opened. Administrator Adam stated that he will get a quote to replace the door tomorrow and provide proof to CCLD by POC due date of 03/11/26. Once the door is replaced, administrator will provide proof.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/10/2026 03:12 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 03/10/2026 at 01:06 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: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that LPA observed the exterior of the house paint peeling off, the gate on the west side of the residence is broken, patch up work is needed in the dining room and hallway entrance, bathroom ceiling is not completely painted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2026
Plan of Correction
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Administrataor stated that he will obtain quotes for the repairs needed and provide proof to CCLD. Once repairs are completed, administrator will provide proof.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MERCIE'S HOME #3
FACILITY NUMBER: 155801220
VISIT DATE: 03/10/2026
NARRATIVE
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Amended Report. Continued from LIC 809.

The carbon monoxide/smoke detector was observed operational during inspection. Medications were reviewed along with MARS and observed to be administered as prescribed. The last fire drill was conducted on 02/05/2026, per staff records. A sample of resident files and staff files were also reviewed and observed to have required documentation.

Deficiencies are being cited on the attached LIC 809D page. Plan of corrections was reviewed and discussed. An immediate civil penalty was assessed in the amount of $500 for fire clearance.



An exit Interview was conducted. A copy of this report and appeal rights were provided to AD, whose signature on this form confirms receipt of this report.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 03/17/2026.
NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
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