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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206576
Report Date: 09/05/2024
Date Signed: 09/05/2024 05:12:13 PM


Document Has Been Signed on 09/05/2024 05:12 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
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:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator/Licensee, Susan and Ulysis BaalTIME COMPLETED:
05:30 PM
NARRATIVE
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On 9/5/2024, Licensing Program Analysts (LPA) K.Kaur arrived at the facility unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry into the facility by staff Justin D. Clemeno. Facility Staff contacted Administrator/Licensee, Susan Baal and Ulysis Baal. Licensees arrived a short time later.

LPA toured the facility inside and out with staff. Facility observed to be clean, odor free and at a comfortable temperature. Pathways and doors were clear and free from obstruction. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. LPA observed sufficient seating in living room. Fire extinguisher last serviced 3/18/2024. LPA toured 4 resident rooms. Two rooms are single occupancy and two are shared. Resident rooms observed to have the required furnishings. At 11:41 AM LPA observed Bedroom Window was missing a screen. Tour continued to Kitchen and dining area which were clean and had sufficient seating. LPA observed 7-day supply of non-perishable foods and 2-day supply of perishable foods. At 11:46 AM LPA observed unlocked medication in the refrigerator. Laundry area toured in the garage. LPA observed locked closet in the garage that has all chemicals. At 12:01 PM LPA observed Ajax container in the hallway bathroom next to the toilet. The exterior tour was conducted. The backyard was observed to have sufficient space and shade under a patio. Licensee states furniture is available for patio when weather is better. At 12:14 PM LPA observed unlocked paint cans in the storage shed. Backyard gate is self-closing and self-latching.

Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report


and ID Documentation. At 2:10 PM LPA observed no residents had Appraisal needs and service plans. Staff files were reviewed for good health and CPR/First Aid. At 2:51 PM LPA reviewed Centrally Stored Medication and Destruction Record (CSMDR) lists, MAR(s) and medication and observed 5 medications from two residents were not logged in the log.

Continued to Next Page
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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 09/05/2024 05:12 PM - 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: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 areas were observed with unlocked chemicals which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Staff locked chemicals 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 and interview, the licensee did not comply with the section cited above in 1out of 1 residents medication was observed unlocked in the kitchen refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Staff removed medication and locked it. Licensee agrees to purchase a separate refrigerator for medication that will be locked.
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: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2024 05:12 PM - 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: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 in 2 out of 2 window screens were missing from resident bedroom and kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Licensee agrees to purchase and replace missing window screens and submit proof of purchase by due date.
Type B
Section Cited
CCR
87465(h)(1)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 5 out of 5 medications were observed to be not logged in the Centrally Stored Medication and Destruction Record (CSMDR) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Licensee agrees to audit all medication and ensure all medication is logged into Centrally Stored Medication Log and complete in-service training and process of when medication should be logged.
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: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 09/05/2024 05:12 PM - 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: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 5 out of 5 residents were missing Appraisal Needs and service plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Licensee agrees to complete Appraisal needs and service plan for all residents and review regulations 87457 Pre-Admission Appraisal – General to be aware of documentation required at admission.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


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
VISIT DATE: 09/05/2024
NARRATIVE
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Deficiencies are being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D.

LPA requested the following documents to be submitted to CCL by 9/19/2024: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.



Exit interview conducted and a plan of correction was reviewed and developed with Licensee/Administrator. A copy of this report and appeal rights was discussed and provided to Administrator, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 8 of 8