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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206576
Report Date: 02/03/2023
Date Signed: 02/06/2023 08:25:50 AM


Document Has Been Signed on 02/06/2023 08:25 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: 5DATE:
02/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator Susan BaalTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced for case management. LPA explained the reason for the visit and requested staff contact AD. 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.

During the tour of the facility LPA observed the cabinet under the sink had a broken lock. Cabinet contained cleaning supplies/chemicals. LPA explained chemicals must remain locked at all times and this is a deficiency. LPA also observed scissor on the counter top and knives left unlocked. LPA did observe caregivers preparing lunch and reminded caregivers to keep all sharps locked and inaccessible to residents. Due to the circumstance no discrepancies were found for the sharps.

An exit interview was conducted, and a copy of this report, LIC809D, and appeal rights were left with AD Susan Baal, whose signature on this form confirm receipt of these documents. Due to LPA having issues with the printer LIC809, LIC809D, and appeal rights sent by email.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/06/2023 08:25 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2023
Section Cited

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
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Chemicals will be removed from under the sink and placed somewhere locked and inaccessible to residents. POC completed today.
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed cleaning supplies/chemicals under the sick with a broken lock.
and accessible to residents. LPA observed knives and others sharps as not locked and accessible to residents.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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