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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206576
Report Date: 08/09/2021
Date Signed: 08/09/2021 11:45:49 AM

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 IIFACILITY NUMBER:
157206576
ADMINISTRATOR:BAAL, SUSAN H.FACILITY TYPE:
740
ADDRESS:809 HEWLETT STREETTELEPHONE:
(661) 374-4600
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:6CENSUS: 6DATE:
08/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Adminstrator, Susan BaalTIME COMPLETED:
11:50 AM
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On 08/09/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct an Annual Inspection - Infection Control. LPA contacted Administrator via telephone, introduced self, and stated the purpose of the visit. Administrator, Susan Baal arrived a short time later. The facility has one central entry and exit point. LPA observed visitor log-in/screening upon entry to the facility.

LPA conducted a facility tour with the Administrator. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Beds in the shared bedrooms were observed to be at least 6 feet apart.

LPAs checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility has a central supply of PPE that is provided to the facility. PPE supplies is checked daily. Staff records were reviewed for good health and infection control training. Facility staff observed to be wearing facial coverings. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Administrator certification is current.

No deficiencies were observed. Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be provided via email and an electronic read receipt confirms receiving this document. Report was signed.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
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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