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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206698
Report Date: 05/12/2022
Date Signed: 05/13/2022 02:31:24 PM

Document Has Been Signed on 05/13/2022 02:31 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 IIIFACILITY NUMBER:
157206698
ADMINISTRATOR:BAAL, SUSAN & ULYSISFACILITY TYPE:
740
ADDRESS:2301 SCARBOROUGH LANETELEPHONE:
(661) 397-4234
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Licensee, Susan and Ulysis BaalTIME COMPLETED:
02:15 PM
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On 5/12/22 at 12:35 PM, Licensing Program Analyst L. Salazar arrived unannounced to conduct an annual inspection. LPA was met by licensees and stated purpose of visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Facility has one main entrance/exit point.

LPA toured the facility inside and out and observed facility to be clean, free from odor without any obstructions or fire clearance issues. LPA toured the facility inside and out. LPA observed a stocked first aid kit. The facility temperature read at 69 degrees. The hot water temperature read at 115 degrees F.
Hand sanitizer was readily available to residents and visitors. Hand washing posters were observed by the bathroom sinks. LPA observed required postings in the facility.

LPA observed a 4 bedroom 2 bathroom house, two bedrooms have twin beds and are shared. LPA observed 4 out of 4 residents in care. Resident R1 is bedridden in bedroom #1 and is receiving Hospice services.

LPA observed a 2 day supply of perishables and 7 day supply of non-perishable foods. Medications were observed in a locked cabinet in the kitchen. Chemicals were in a locked cabinet under the sink in the kitchen. LPA observed knobs removed from the stove and door signals on the door for dementia residents.

Current Liability insurance certificate was observed with am expiration of August 2022. Both Licensees carry current administrators certifications with expirations dates of 2023.

(continued on 809-C)
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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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 III
FACILITY NUMBER: 157206698
VISIT DATE: 05/12/2022
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(Continued from 809)

LPA provided technical assistance for Hospice Care, Home Health care, Allowable, Restricted and Prohibited conditions.

Exit interview was conducted. A copy of this report was left with Licensee Susan/Ulysis Baal. No deficiencies observed on todays inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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