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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206681
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:04:45 PM


Document Has Been Signed on 04/14/2022 12:04 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
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: 6DATE:
04/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Nemia Ong, LicenseeTIME COMPLETED:
12:00 PM
NARRATIVE
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On 04/14/22, Licensing Program Analyst (LPA) M. Yang conducted an unannounced case management inspection regarding incident report received from facility on 12/29/21. LPA met with Licensee Nemia Ong.

On 12/29/21, the department received a special incident report, facility report a resident passing on 12/28/21. Interviews were conducted, incident report and records were reviewed regarding the passing of the resident. During the course of the investigation, it was discovered that the staff called the Licensee before calling medical emergency 9-1-1 on 12/28/21.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.

Exit Interview conducted. As a COVID-19 precautionary measure, a copy of this report and appeal rights will be provided via email. Report signed on site.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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Document Has Been Signed on 04/14/2022 12:04 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: DIVINE MERCY HOME CARE
FACILITY NUMBER: 157206681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2022
Section Cited

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87465 (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).

This requirement was not met as
evidenced by:
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Based on interviews conducted and records review, the Licensee informed staffs to call Licensee before calling 9-1-1 for any medical emergency this poses a potential health and safety risk to residents in care.
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Licensee agreed to train staff on steps to take during a life-threatening medical crisis. Plan will include calling medical emergency 9-1-1 immediately for any injury and life threatening medical crisis. Documentation of training topics and attendance will be submitted to the Fresno CCL office by 04/20/22.

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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: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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