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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206576
Report Date: 04/11/2023
Date Signed: 04/14/2023 09:27:11 AM


Document Has Been Signed on 04/14/2023 09:27 AM - 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 IIFACILITY NUMBER:
157206576
ADMINISTRATOR:BAAL, SUSAN H.FACILITY TYPE:
740
ADDRESS:809 HEWLETT STREETTELEPHONE:
(661) 374-4600
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:6CENSUS: DATE:
04/11/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Administrator Ulysis BaalTIME COMPLETED:
02:15 PM
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On 4/1//23 at 1:55 p.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility as an announced visit to collect original report and provide amended report. LPA was greeted by Administrator Ulysis Baal, explained the reason for the visit, and allowed entry into the facility.

LPA explained the original report needs to be collected. Original report was previously emailed due to LPA having printer issues. LPA informed Administrator the email sent on 2/6/23 containing the original report is no longer valid. Amended report was provided today 4/11/2023.

Exit interview conducted and LIC809 & amended report provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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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