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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201087
Report Date: 07/19/2022
Date Signed: 07/19/2022 12:04:02 PM

Document Has Been Signed on 07/19/2022 12:04 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: 5DATE:
07/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Gerald De Claro, Administrator
Lynell Rattler, House Manager		TIME COMPLETED:
12:20 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 7/19/22 at 10:30 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other inspection. LPA contacted Administrator (ADM) Gerald De Claro via telephone and explained reason for inspection. ADM arrived a short time later. There was no staff or residents present during the inspection.

LPA returned R's file that was removed from the facility on 7/15/22. During records review, LPA found that R1 has dementia and the last obtained medical assessment was completed on 1/13/17. Facility has not completed an annual reappraisal assessment of R1 and does not have records of any prior reappraisals completed.

Deficiency is being cited based on records review in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report and appeal rights were given to Co-Administrator Gerald De Claro, whose signature confirms receipt of this report. A Plan of Correction was completed with Administrator Gerald De Claro.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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 2
Document Has Been Signed on 07/19/2022 12:04 PM - It Cannot Be Edited


Created By: Malia Thao On 07/19/2022 at 11:52 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: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2022
Section Cited
CCR
87705(c)(5)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will submit proof of current medical assessment and reappraisal for R1 to CCL by POC due date.
8
9
10
11
12
13
14
During records review, LPA found that R1 has dementia and the last obtained medical assessment was completed on 1/13/17, and the facility has not completed an annual reappraisal assessment of R1 and does not have records of any prior reappraisals completed, which poses a potential health risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2