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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002817
Report Date: 10/06/2021
Date Signed: 10/06/2021 11:25:12 AM

Document Has Been Signed on 10/06/2021 11:25 AM - 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MERYL'S CARE HOMEFACILITY NUMBER:
345002817
ADMINISTRATOR:ABELARDO, BERYLFACILITY TYPE:
740
ADDRESS:9495 DEANNA AVE.TELEPHONE:
(916) 467-2492
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 0DATE:
10/06/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Beryle AbelardoTIME COMPLETED:
11:45 AM
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
LPA Lusby and LPA Williams arrived on Wednesday October 6, 2021 to conduct the prelicensing inspection. Prior to the visit, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask by LPA Lusby and a surgical mask by LPA Williams.

LPAs completed the prelicensing inspection domain with Licensee Beryle. LPAs toured the facility and insured all rooms had the required furniture. LPAs requested that Licensee Beryle update her inside facility sketch to reflect the accurate staff room location. LPAs obtained LIC808 mitigation plan for the facility.

Component III was conducted with Licensee. Upon review of updated approved facility sketch, LPAs will notify CAB that the facility is ready for licensure.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Melissa Lusby
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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 1