157203382-10-26-2023-24-AS-DWIS-CWZ2J5-20231026172547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157203382
Report Date: 10/26/2023
Date Signed: 10/26/2023 05:26:25 PM

Document Has Been Signed on 10/26/2023 05:26 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:	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:	10/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Administrator Susan Baal		TIME COMPLETED:	01:50 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	Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Annual Inspection visit. LPA met with Administrator Susan Baal and discussed the purpose of the visit. LPA observed three residents sitting in the living room watching t.v. There was enough space in the living room to accommodate seating for six resident. The kitchen was sanitary and in good repair. The refrigerator reflected approximately and the freezer approximately The dining room table and chairs were in good repair and there was enough seats for 6 residents. LPA toured four bedrooms. There were beds, with required linens, chairs, nightstands, and tables. All rooms had working lights had space to accommodate the residents to move around unobstructed. Bathroom was free of odor and in good repair. There were grab bars and non-slip mats present for resident use. First aid kit was present and had required items. Facility had gloves, masks, gowns, and other items for infection control. LPA observed chemical and medications locked and inaccessible to residents. Smoke detector and carbon monoxide were present and operational. Continued on LIC-809C

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/26/2023

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LPA Williams reviewed 5 resident files which had all documents that the LPA requested. Additionally, 3 employee files were reviewed and had all paperwork request by the LPA.

LPA Williams requested an updated copy of liability insurance to the Department by 10/27/2023.

No deficiencies were cited during the visit.

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: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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