157206576-4-11-2023-24-AS-BCHN-CQVV6N-20230414160947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157206576
Report Date: 02/03/2023
Date Signed: 04/11/2023 02:06:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2023 and conducted by Evaluator Brianna Miranda

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230125091224

FACILITY NAME:	DIVINE MERCY GUEST HOME II		FACILITY NUMBER:	157206576
ADMINISTRATOR:	BAAL, SUSAN H.		FACILITY TYPE:	740
ADDRESS:	809 HEWLETT STREET		TELEPHONE:	(661) 374-4600
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93309
CAPACITY:	6	CENSUS: 5	DATE:	02/03/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Susan Baal		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility not providing proper medical care for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to investigate a complaint. LPA explained the reason for the visit and requested staff contacted Administrator. LPA was met by caregiver S1 who greeted and allowed entry into the facility. Caregiver S2 contact Administrated (AD) and completed tour with LPA. AD arrived later.
S2 stated there are currently 5 residents at the facility. LPA observed all residents in their rooms. One room was shared by 2 males residents, another room is waiting for the arrival of a new resident, another room had one resident asleep, and the last room was shared by two female residents.

LPA requested a copy of personnel roster and resident roster with emergency contact information.
1. The Department investigated the allegation: Facility not providing proper medical care for residents. Multiple residents were interviewed. None of the residents who were interviewed voiced concerns regarding medical needs were not being met.
See LIC9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230125091224

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 II	FACILITY NUMBER: 157206576
	VISIT DATE: 02/03/2023

NARRATIVE

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Based on interviews conducted and record reviews, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Verification of doctor's appointment was provided for resident R1.

No citation was issued for the allegation.

An exit interview was conducted, and a copy of this report was left with AD Susan Baal, whose signature on this form confirm receipt of these documents. Due to printer issues LPA emailed LIC9099.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC9099 (FAS) - (06/04)

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