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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206697
Report Date: 05/18/2023
Date Signed: 05/30/2023 01:04:31 PM


Document Has Been Signed on 05/30/2023 01:04 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 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: DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Administrator Susan BaalTIME COMPLETED:
01:36 PM
NARRATIVE
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced annual inspection visit. LPA Williams met with Administrator Susan Baal, and discussed the purpose of the visit.

LPA and the Administrator toured the facility.

The kitchen was clean and in good repair. Medications were observed behind a locked cabinet inaccessible to residents. Refrigerator temperature reflected approximately 53 degrees Fahrenheit (F) via LPA handheld thermometer and freezer reflected 0 degrees F. Water temperature reflected approximately 109.1 degrees F.

Dining room and living room were clean and in good repair. There was seating present to accommodate all residents.

The hallway closet housed extra linens for residents.

The LPA toured all bedrooms. All bedrooms had beds, required linens, chair, dresser, night stand, lamp, and space to accommodate residents.

The LPA toured two bathrooms. Both bathrooms had non-slip mats and grab bars to assist residents as needed.

The backyard space had a covered patio to keep residents out of the elements, and seating to accommodate. There is no pool on the premises.

*Continued on LIC 809-C*
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
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


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
VISIT DATE: 05/18/2023
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Smoke detectors, carbon monoxide, and fire extinguisher were present and operational.

LPA Williams reviewed 6 resident files. LPA reviewed Admission agreement and observed an addendum regarding refund policies. LPA Williams discussed with the Administrator changes to the policy to bring it in line with the California Health and Safety Code.

Based on LPA's observation a deficiency is being cited on the attached LIC 809-D page. Refrigerator temperature reflected approximately 53 degrees F, via LPA Williams thermometer. Based on Title 22, Division 6, regulation, the maximum temperature allowed is 40 degrees F. The Administrator attempted to lower the temperature with no success. LPA tested refrigerator 3 times over a period of approximately 10 minutes.

A plan of correction was discussed and reviewed with the Administrator.

An exit interview was conducted and a copy of this report and appeal rights will be provided via e-mail.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/30/2023 01:04 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 GUEST HOME IV
FACILITY NUMBER: 157206697

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
CCR
87555(b)(21)

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(b) The following food service requirements shall apply:(21)...refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C)...

This requirement was not met evident by:
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Administrator reported she will consult a technician on 5/18/2023 to check/fix the refrigerator. Administrator reported if refrigerator can not be fixed they will purchase a new one by Monday 5/22/2023.
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Based on LPA Williams observation, the refrigerator temperature could not reach a temperature lower than 53 degrees F. which poses a potential health and safety risk to persons in care.
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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: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
LIC809 (FAS) - (06/04)
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