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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206576
Report Date: 08/22/2022
Date Signed: 08/30/2022 08:27:58 AM


Document Has Been Signed on 08/30/2022 08:27 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
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: 3DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Susan Baal, Licensee/AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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On 8/22/22 at 8:50 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensees Susan Baal and Ulysis Baal arrived a short time later.

LPA toured inside and outside of the facility. No obstructions observed and pool gate in backyard was observed locked and inaccessible. 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. LPA checked residents’ locked medications and observed a 30-day supply. Food supply was checked. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Facility staff observed to be wearing facial coverings. Resident’s files have updated emergency contact information. Administrator certification is current.

The following deficiencies were observed:
1. S1 was working in the facility and was not associated to the facility. S1 had worked two days in the facility.
2. LPA found that the cabinet door, where centrally stored medication is kept, was unlocked and accessible.

Deficiencies are being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A civil penalty is being assessed in the amount of $100 per day, for a total of $200. See LIC421BG for more details.

An exit interview was conducted. A copy of this report and appeal rights were discussed and left with Licensee Susan Baal, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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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Document Has Been Signed on 08/30/2022 08:27 AM - 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: DIVINE MERCY GUEST HOME II
FACILITY NUMBER: 157206576

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. S1 was working in the facility and had worked two days, and was not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2022
Plan of Correction
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Licensee completed fingerprint transfer for S1 on Guardian website. POC cleared during inspection.
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, the licensee did not comply with the section cited above. LPA found that the cabinet door, where centrally stored medication is kept, was unlocked and accessible, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2022
Plan of Correction
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Licensee immediately locked the cabinet. POC cleared during the inspection.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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