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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203382
Report Date: 10/16/2026
Date Signed: 10/16/2026 03:50:36 PM

Document Has Been Signed on 10/16/2026 03:50 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DIVINE MERCY GUEST HOME IFACILITY NUMBER:
157203382
ADMINISTRATOR/
DIRECTOR:		BAAL, SUSAN H.FACILITY TYPE:
740
ADDRESS:6108 COCHRAN DRIVETELEPHONE:
(661) 852-0464
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 6DATE:
10/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Administrator Susan Baal TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 10/16/2026, Licensing Program Analyst (LPA) J. Duarte arrived unannounced to conduct the required Annual inspection. LPA introduced self, stated the purpose of the visit, and met with Direct Care Staff (DCS) Nonie Barrameda. Staff contacted Administrator (AD) Ulysis Baal. AD Ulysis Baal and DCS John Clemeno arrived to assist with this visit.

The facility was observed to be at a temperature of 77 degrees F, in good repair, and no passageway obstructions were observed. The living room has adequate seating for residents. The kitchen was toured and LPA observed a two day supply of perishable food and a seven day supply of non perishable food. The facility stores sharps in a locked kitchen cabinet. Medication is also stored in a locked kitchen cabinet. A fire extinguisher was observed in the kitchen, with a service date of 06/26/2026. LPA observed insulin medication in the kitchen fridge in a ziplock bag, on a shelf, accessible to residents in care. S3 stated that it is there medication. Pharmacy label on medication showed S3's name.

Resident bedrooms were toured and observed to have beds, dressers, chairs, and adequate lighting. Bathrooms were observed operational, with non-skid mats and grab bars. The restrooms hot water measured between 112 and 118 degrees F. LPA observed R1 to have a cream in their room. R1 stated that they apply this cream on themselves. However, S2 stated that the cream is for redness and itching and S2 applies it on R1.

The facility has a laundry room, with a washer and dryer. The facility conducts their own laundry. The garage was toured and LPA observed detergent, chemicals, and hygiene products locked in a cabinet. The facility has a freezer in the garage with an additional supply of frozen food. The facility had over six medications bottles, some with pills and some empty in a locked garage cabinet. S1 stated that the medications were expired.

Continued in LIC 809C.

Alexandria Walton
Jimmy Duarte
DATE: 10/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
Document Has Been Signed on 10/16/2026 03:50 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 10/16/2026 at 02:53 PM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME I
FACILITY NUMBER: 157203382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(i)
87465 Incidental Medical and Dental Care
(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facillity had over six medications bottles in a locked garage cabinet, some with pills and some empty. S2 stated that the medications were expired and had not been disposed of, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2026
Plan of Correction
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Administrator, stated that the will dispose of medications accordingly and will submit a statement stating when and how medications were disposed and provide photograps of the garage cabinet were the medications bottles were stored.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/16/2026 03:50 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 10/16/2026 at 03:01 PM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME I
FACILITY NUMBER: 157203382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in that, LPA observed R1 to have a cream in their room. R1 stated that they apply this cream to their face. However, S2 stated that the cream is for redness and itching for R1's bottom. S2 stated that they apply it to R1 when R1 has redness on their bottom. S2 stated that the cream is supplied by home health with the diapers and bed pads. In addition, LPA observed insulin medication in the kitchen fridge in a ziplock back. S3 stated that it is their medication. Pharmacy label showed S3's name.This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2026
Plan of Correction
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Administrator removed the cream from R1's room. The administrator removed S3's medication from the fridge and placed it in the locked mini fridge. Administrator stated they will review regulation 87465(h)(2) and coduct training. Administrator will provide a statement by 10/17/2026 to indicate the training that will be conducted, when it will be conducted, and which staff will be participating. Administrator stated that all staff will be trained by 10/23/2026 and will provide a staff participant sign in sheet to CCLD once training has been completed.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that In review of R2's medication, MARs, and Centrally stored list, R2 was prescribed the medication, Muro, and MARs indicate: Instill three drops with one minute interval on each eye, four times a day. The facility has a log for R2's eye drops and the last time the the log was signed was on 10/12/2026 for 8:00 AM. LPA asked S2, if the medication is still being administered to R2. S1 and S2 stated that they are not sure if the drops are still being administered or not. S2 stated that it is possible that staff did not sign, but there's no way of confirming this. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2026
Plan of Correction
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Administrator stated they will review regulation 87465(c)(2) and coduct training. Administrator will provide a statement by 10/17/2026 to indicate the training that will be conducted, when it will be conducted, and which staff will be participating. Administrator stated that all staff will be trained by 10/23/2026 and will provide a staff participant sign in sheet to CCLD once training has been completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/16/2026 03:50 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 10/16/2026 at 03:01 PM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME I
FACILITY NUMBER: 157203382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that S1 stated that R3 is on hospice. Per R3's file, there is documentation that R3 is on hospice and there is a POC summary that states current as of 07/23/2026. S1 confirmed that R3 is on hospice. LPA asked for the Hospice Plan of Care. However, S1 stated that they do not have one in the facility, but could request a copy. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
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The administrator requested a copy of the Hospice Plan of Care and will submit a copy to CCLD by POC due date of 10/23/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 10/16/2026
NARRATIVE
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Continued from LIC 809.

Outside of the facility toured and observed to be free of debris. The gate on the side was observed to be self closing. The backyard patio provides shaded seating for residents.

The carbon monoxide/smoke detectors were observed operational during inspection. A first aid kit is stored in the kitchen. All resident files and a sample of staff files were reviewed. Staff files had required documentation. Per R3's file, there is documentation that R3 is on hospice and there is a POC summary in R3's file that states current as of 07/23/2026. S1 confirmed that R3 is on hospice. LPA asked for the Hospice Plan of Care. However, S1 stated that they do not have the Hospice Plan of Care in the facility, but could request a copy.

LPA reviewed a sample of medication along with the centrally stored log and the MARs log. In review of R2's medication, MARs, and Centrally stored list, R2 was prescribed the medication, Muro, and MARs indicate: Instill three drops with one minute interval on each eye, four times a day. The facility has a log for R2's eye drops and the last time the the log was signed was on 10/12/2026 for 8:00 AM. LPA asked S2, if the medication is still being administered to R2. S2 stated that they are not sure if the drops are still being administered or not. S2 stated that it is possible that staff did not sign the log, but there's no way of confirming this.



Deficiencies are being cited on the attached LIC 809D in accordance to California Code of Regulations, Title 22. A plan of correction was developed for deficiencies issued.

An exit Interview was conducted and a copy of this report and appeal rights were provided to AD Ulysis Baal.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 10/23/2026.
NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2026
LIC809 (FAS) - (06/04)
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