157203382-11-4-2024-24-AS-KKAR-DAQ24T-20241104160428

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157203382
Report Date: 11/04/2024
Date Signed: 11/04/2024 04:07:23 PM

Document Has Been Signed on 11/04/2024 04:07 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	DIVINE MERCY GUEST HOME I		FACILITY NUMBER:	157203382
ADMINISTRATOR/ DIRECTOR:	BAAL, SUSAN H.		FACILITY TYPE:	740
ADDRESS:	6108 COCHRAN DRIVE		TELEPHONE:	(661) 852-0464
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93309
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Administrator/Licensee, Susan Baal and Ulysis Baal		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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On 11/4/2024, Licensing Program Analyst (LPA) K.Kaur arrived at the facility unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry into the facility by staff John Kevin Clemeno. Facility Staff contacted Administrator/Licensee, Susan Baal and Ulysis Baal. Licensees arrived a short time later.

LPA toured the facility inside and out with staff. Facility observed to be clean, odor free and at a comfortable temperature. Pathways and doors were clear and free from obstruction. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. LPA observed sufficient seating in living room. Fire extinguisher last serviced 3/18/2024. LPA toured 4 resident rooms. Two rooms are single occupancy and two are shared. Resident rooms observed to have the required furnishings. At 11:34 AM LPA observed Bedroom #2 had a window screen that was torn. Tour continued to Kitchen and dining area which were clean and had sufficient seating. LPA observed 7-day supply of non-perishable foods and 2-day supply of perishable foods. Laundry area toured next to kitchen. LPA observed locked closet in the garage that has all chemicals. The exterior tour was conducted. The backyard was observed to have sufficient space and shade under a patio. Backyard gate is self-closing and self-latching.

Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report

and ID Documentation. At 1:15 PM LPA observed no training for restricted health care conditions. Staff files were reviewed for good health and CPR/First Aid. At 2:51 PM LPA reviewed Centrally Stored Medication and Destruction Record (CSMDR) lists, MAR(s) and medication and observed 2 medications from 1 resident were not logged in the log. Medication counts also did not align with medication records for R1. R1 only had centrally stored medication records for current year and did not have previous records. Based on record review LPA observed Facility did not have a care plan from palliative agency for R2

Continued to Next Page

See Moua	TELEPHONE: (559) -58-4596
Kamaldeep Kaur	TELEPHONE: 559-243-8080
	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

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 11/04/2024 04:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME I	FACILITY NUMBER: 157203382
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Allowable Health Conditions and the Use of Home Health Agencies

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 6 residents did not have a care plan from Palliative Care Agency which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/05/2024
	Plan of Correction
1 2 3 4	Licensee to obtain a care plan from Palliative care for R2 and submit copies to CCLD by due date.

Section Cited

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 6 residents did not have a centrally stored medication log older than current year and medication that was not logged which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/05/2024
	Plan of Correction
1 2 3 4	Licensee agrees to schedule in-service training by due date and submit records of training when completed. Licensee agrees to audit all residents’ records to ensure all medication is logged.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -58-4596
Kamaldeep Kaur	TELEPHONE: 559-243-8080
	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/04/2024 04:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME I	FACILITY NUMBER: 157203382
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the licensee did not comply with the section cited above in 3 out of 3 window screens were torn, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/11/2024
	Plan of Correction
1 2 3 4	Licensee agrees to repair or replace window screens and submit pictures once completed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -58-4596
Kamaldeep Kaur	TELEPHONE: 559-243-8080
	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME I	FACILITY NUMBER: 157203382
	VISIT DATE: 11/04/2024

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Deficiencies are being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D.

LPA requested the following documents to be submitted to CCL by 11/11/2024: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview conducted and a plan of correction was reviewed and developed with Licensee/Administrator. A copy of this report and appeal rights was discussed and provided to Administrator, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

LIC809 (FAS) - (06/04)

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