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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157203382
Report Date: 05/22/2025
Date Signed: 05/22/2025 04:22:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
05/19/2025 and conducted by Evaluator Jacques Leffall
COMPLAINT CONTROL NUMBER: 24-AS-20250519155637
FACILITY NAME:DIVINE MERCY GUEST HOME IFACILITY NUMBER:
157203382
ADMINISTRATOR:BAAL, SUSAN H.FACILITY TYPE:
740
ADDRESS:6108 COCHRAN DRIVETELEPHONE:
(661) 852-0464
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:6CENSUS: 6DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Staff: Kevin ClemenoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff screams at residents.

INVESTIGATION FINDINGS:
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On 5/22/25 at 2:00 pm Licensing Program Analyst (LPA) J. Leffall conducted an initial complaint visit to investigate and deliver findings on above allegations. LPA met with Staff (S1) John Kevin Clemeno and stated purpose of visit.

The Department reviewed records and conducted interviews. R2 stated staff has yelled at resident.

Based on the interviews conducted, the preponderance of evidence that Staff yelled at Resient is substantiated. Citation is issued on the attached 9099D.

Exit interview conducted. Appeal Rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20250519155637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME I
FACILITY NUMBER: 157203382
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2025
Section Cited
CCR
87468.1(a)(1)
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(a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities, and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility.

(1) "Privately operated facility" means a residential care facility for the elderly that is licensed to an individual, firm, partnership, association, or corporation.

Based on interview, the licensee did not comply with the section cited that staff yells at resident which poses/posed a potential health, safety or personal rights risk to persons in care.
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Licensee agrees to provide Personal Rights training and will submit completion documents to CCLD by POC due date.
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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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2