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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426418
Report Date: 06/24/2021
Date Signed: 06/24/2021 12:01:06 PM

Document Has Been Signed on 06/24/2021 12:01 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:M&M BOARD & CAREFACILITY NUMBER:
366426418
ADMINISTRATOR:MERCADO, VICTORFACILITY TYPE:
740
ADDRESS:18245 CHERRY ST.TELEPHONE:
(760) 488-1698
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 8CENSUS: 5DATE:
06/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator Victor MercadoTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George conducted an unannounced case management deficiencies visit to the facility. LPA met with Administrator Victor Meracdo and explained the purpose of the visit. LPA toured the facility and made the following observations.

LPA observed at 10:37am mice droppings, and a sticky trap in the pantry that is being used to store the canned foods, cereal and pasta. LPA inquired if the exterminator had recently come out to the facility. Administrator Victor stated that the exterminator company was supposed to come out to the facility today (6/24) at 2:30pm.

At 10:50am LPA observed in the bathroom/walkway by bedroom number 4, four dead cockroaches. LPA asked if the exterminator was aware that there were cockroaches in the facility. Administrator Victor stated that he only told the extermination company about the rats, and mice and upon the exterminator's tour and any observations made would be added to the list. Administrator stated that he does spray the interior of the exterior of the facility two times a month.

Based on observation deficiencies were observed and will be cited according to California Code of Regulations.

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator Victor Mercado.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2021
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 06/24/2021 12:01 PM - It Cannot Be Edited


Created By: Javina George On 06/24/2021 at 11:08 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: M&M BOARD & CARE
FACILITY NUMBER: 366426418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2021
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
Based on observations LPA observed 4 dead cockroaches and mice droppings in the facility during a tour of the home. This poses an immediate health and safety risk to residents in care.
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Administrator/Licensee shall call and exterminator within 24 hours to have exterminator services performed on the inside and outside of the home and a plan of procedure shall be submitted to LPA no later than 5pm on 6/25/21 regarding mice and or rat and roach infestation. LPA will also receive all invoices and receipts of services for the bed bugs and roach infestation once perfomred no more than 24 hours after services performed.

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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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021


LIC809 (FAS) - (06/04)
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