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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206576
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:44:32 PM


Document Has Been Signed on 05/17/2022 02:44 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 IIFACILITY NUMBER:
157206576
ADMINISTRATOR:BAAL, SUSAN H.FACILITY TYPE:
740
ADDRESS:809 HEWLETT STREETTELEPHONE:
(661) 374-4600
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:6CENSUS: 0DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Susan Baal, LicenseeTIME COMPLETED:
03:00 PM
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On 5/17/22 at 12:30 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other inspection. R1 now resides at Divine Mercy Guest Home IV #157206697. LPA conducted inspection and interview at Divine Mercy Guest Home IV.

On 2/4/22, CCL received an incident report concerning R1. LPA conducted interview and reviewed records. Due to time constraints, LPA will return to continue the case management inspection.

Exit interview conducted. A copy of this report was provided to Licensee Susan Baal, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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