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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201087
Report Date: 09/03/2021
Date Signed: 09/03/2021 02:34:33 PM

Document Has Been Signed on 09/03/2021 02:34 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 #5FACILITY NUMBER:
157201087
ADMINISTRATOR:PENAREJO, MERCEDESFACILITY TYPE:
740
ADDRESS:812 SESNON STREETTELEPHONE:
(661) 323-0462
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 6DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Elena Penarejo, Co-AdministratorTIME COMPLETED:
10:30 AM
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On 9/3/21 at 8:30 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. Co-Administrator Elena Penarejo arrived a short time later.

Facility was observed clean and without any obstructions or fire clearance issues. 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. There are two shared bedrooms. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Residents files have updated emergency contact information. Administrator certification is valid.

LPA observed the following deficiency:

1. Window screens for bedrooms #1, 2, and 3 are bent, covered in dust/dirt, and in disrepair.

Deficiency is being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.



The following updated forms are to be sent to CCL within 2 weeks:
LIC500, LIC400, LIC610E, LIC308 and surety bond.

Exit interview conducted. A copy of this report and appeal rights were discussed and emailed to Co-Administrator Elena Penarejo at ebpenarejo@gmail.com.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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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Document Has Been Signed on 09/03/2021 02:34 PM - It Cannot Be Edited


Created By: Malia Thao On 09/03/2021 at 10:10 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MERCIE'S HOME #5
FACILITY NUMBER: 157201087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
87303 Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The window screens in bedrooms #1,2, and 3 are all bent, covered in dust/dirt, and in disrepair, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2021
Plan of Correction
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Co-Administrator states she will submit proof of window screens replaced for bedrooms #1,2, and 3 to CCL by POC due date.
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.
SUPERVISOR'S NAME:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021


LIC809 (FAS) - (06/04)
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