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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206697
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:45:14 PM


Document Has Been Signed on 05/17/2022 02:45 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 GUEST HOME IVFACILITY NUMBER:
157206697
ADMINISTRATOR:BAAL, SUSAN H.FACILITY TYPE:
740
ADDRESS:704 HEWLETT STREETTELEPHONE:
(661) 321-0144
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:6CENSUS: 6DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susan Baal, LicenseeTIME COMPLETED:
12:30 PM
NARRATIVE
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On 5/17/22 at 10:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. Licensee (LIC) Susan Baal arrived a short time later.

LPA conducted tour with staff and did not observed any obstructions. No fire issues observed. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and residents share bedrooms. LPA checked residents’ medications. Cleaning and PPE supplies were checked. Administrator has current certificate. Staff records checked for good health.

The following deficiencies were observed:
1. Padlock for cabinet under kitchen sink was hooked into latch, but was not locked and was accessible to the two cans of Comet cleaner inside the cabinet.
2. Hall bathroom faucet observed with water leaking. Sliding door observed not able to be opened or closed with ease.

The following updated forms to be sent to CCL within 2 weeks: LIC500, LIC400, LIC402, LIC610E

Deficiencies are being cited based on LPA's observations and interview in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report and appeal rights were given to Licensee Susan Baal, whose signature confirms receipt of this report.

SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/17/2022 02:45 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 GUEST HOME IV
FACILITY NUMBER: 157206697

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. Hall bathroom shower faucet observed with water leaking and sliding door observed not able to be opened or closed with ease, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee will submit proof of hall bathroom shower faucet replaced and proof of sliding door replaced or repaired to be able to be opened with ease to CCL by POC due date.
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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/17/2022 02:45 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 GUEST HOME IV
FACILITY NUMBER: 157206697

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. LPA observed padlock for cabinet under kitchen sink was hooked into latch, but was not locked and was accessible to the two cans of Comet cleaner inside the cabinet, which poses an immediate safety or personal rights risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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Licensee immediately locked padlock, securing the inaccessibility of the two cans of Comet cleaner. POC cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3