157203382-7-13-2023-24-AS-SPIY-CTVQBN-20230719120148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157203382
Report Date: 07/13/2023
Date Signed: 07/13/2023 03:44:50 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2023 and conducted by Evaluator Darius Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230428163034

FACILITY NAME:	DIVINE MERCY GUEST HOME I		FACILITY NUMBER:	157203382
ADMINISTRATOR:	BAAL, SUSAN H.		FACILITY TYPE:	740
ADDRESS:	6108 COCHRAN DRIVE		TELEPHONE:	(661) 852-0464
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93309
CAPACITY:	6	CENSUS: 6	DATE:	07/13/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator, Susan Baal		TIME COMPLETED:	10:06 AM

ALLEGATION(S):

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Resident developed bed sore due to staff neglect
Facility is not providing resident with hygiene care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced follow up visit. LPA met with Administrator Susan Baal and discussed the purpose of the visit.

LPA has conducted interview, observations, and record review.

Resident 1's medical assessment, identified wounds, prior to admission. R1 was under the care of Hospice who was attending to the wound care.

According to R1, Administrator, and staff there are no wounds. R1 pointed to where the wound use to be and LPA did not observe any wounds.

R1 reports staff assist with washing, dressing, toileting, brushing hair, etc.

*Continued on LIC 9099-C*

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230428163034

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME I	FACILITY NUMBER: 157203382
	VISIT DATE: 07/13/2023

NARRATIVE

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Based on the LPA,s observation, interview, and record review the allegations resident developed bed sore due to staff neglect and facility is not providing resident with hygiene care, we have found that the complaint was UNFOUNDED, which means it could not have happened, and/or is without a reasonable basis, therefore we have dismissed the complaint.

An exit interview was conducted and a copy of this report will be provided via e-mail.

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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