157206697-6-5-2020-24-AS-SPIY-BQDQ8L-20200608115652

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157206697
Report Date: 03/26/2020
Date Signed: 06/05/2020 11:05:25 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2020 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20200320105534

FACILITY NAME:	DIVINE MERCY GUEST HOME IV		FACILITY NUMBER:	157206697
ADMINISTRATOR:	BAAL, SUSAN H.		FACILITY TYPE:	740
ADDRESS:	704 HEWLETT STREET		TELEPHONE:	(661) 321-0144
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93309
CAPACITY:	6	CENSUS: 6	DATE:	03/26/2020
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Susan Baal		TIME COMPLETED:	10:53 AM

ALLEGATION(S):

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Facility staff did not provide resident with an adequate amount of food.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Les Xiong conducted the complaint investigation visit to the facility.
During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Facility staff did not provide resident with an adequate amount of food is UNFOUNDED. Resident R1 has a medical malnutrition condition which cause weight loss and she also her mild cognitive impairment which effects her memory so she doesn't remember things correctly.

This agency has investigated the complaint alleging facility staff did not provide resident with an adequate amount of food. We have found that the complaint was unfounded, therefore we have dismissed the complaint.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Les Xiong	TELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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