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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206698
Report Date: 09/07/2023
Date Signed: 09/07/2023 04:15:42 PM


Document Has Been Signed on 09/07/2023 04:15 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: 6DATE:
09/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Administrator, Susan BaalTIME COMPLETED:
01:18 PM
NARRATIVE
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Licensing Program Analyst (LPA) Darius Williams conducted a visit. LPA Williams met with Administrator Susan Baal and discussed the purpose of the visit.

On 6/11/2023, Staff 1 (S1) accepted Resident 1 (R1) into the facility. LPA Williams reviewed R1's file and did not locate a Pre-Admission Appraisal. According to the Administrator, everything was going fast and there was no time to conduct the Pre-Admission appraisal.

Based on record review and interviews, a deficiency is being cited for the following violation on attached LIC 809D page: Title 22, Division 6, Chapter 8, Article 8, Section 87457(a).

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

An exit interview was conducted and a copy of this report 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: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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 09/07/2023 04:15 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 III
FACILITY NUMBER: 157206698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
CCR
87457(a)

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(a)Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions.

This requirement was not met evident by:
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Licensee agreed to read regulation 87457 and provide to the email confirmation to Department that the Licensee has read and understood regulation 87457 by POC due date 9/8/2023.
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Based on interview and record review a Pre-admission appraisal was not conducted for 1 out of 6 residents, which poses a potential health and safety risk for person 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: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
LIC809 (FAS) - (06/04)
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