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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002817
Report Date: 10/22/2021
Date Signed: 10/22/2021 01:46:31 PM

Document Has Been Signed on 10/22/2021 01:46 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, 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:
10/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Beryl AbelardoTIME COMPLETED:
01:50 PM
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On 10/22/2021 at 1:30PM Licensing Program Analysts (LPAs) Lusby and LPA Williams arrived 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 observed two single action locks have been installed on the deck gate and side gate, respectively. Facility is ready for licensure, LPA will notify CAB today.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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