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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206681
Report Date: 01/05/2022
Date Signed: 01/05/2022 09:46:16 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: 4DATE:
01/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Licensee, Nemia OngTIME COMPLETED:
09:50 AM
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On 01/05/2022, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct a Case Management - Other visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Licensee, Nemia Ong.

The purpose of today's visit is to return Resident R1, Resident R2, and Resident R3's facility files that were removed for copying on 12/31/2021 by LPA L. Salazar.

LPA Walton and Licensee Nemia Ong singed the release form that was presented at the time of removal acknowledging that all files have been returned on this date.

No deficiencies issued. Exit interview conducted. As a COVID-19 precautionary measure, a copy of this report will be provided to Licensee via email and an electronic read receipt confirms receiving this document. Report signed on-site by facility representative.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
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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