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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206681
Report Date: 12/31/2021
Date Signed: 12/31/2021 11:27:17 AM

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 HOME CAREFACILITY NUMBER:
157206681
ADMINISTRATOR:ONG, NEMIAFACILITY TYPE:
740
ADDRESS:10239 LANESBORUGH AVE.TELEPHONE:
(661) 412-4845
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 3DATE:
12/31/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Nemia Ong. Licensee TIME COMPLETED:
11:45 AM
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On 12/31/2021, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management visit to amend a previous report that was issued on 11/12/2021.

During the course of the visit, LPA toured the facility and observed 3 out of 3 residents in care. 1 out of 3 resident's in care is currently on Hospice. LPA has requested and obtained files for Resident R1, Resident R2 and Resident R3.

LPA is removing the files from the facility for copying purposes and will return the files within 3 working days. LPA has left a signed release form the file removal with Licensee. LPA and Licensee have both signed the document acknowledging the removal and return date.

No deficiencies cited on today's inspection.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021
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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