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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209212
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:03:26 PM


Document Has Been Signed on 04/14/2022 12:03 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 HOME CAREFACILITY NUMBER:
157209212
ADMINISTRATOR:ONG, NEMIA C.FACILITY TYPE:
740
ADDRESS:10239 LANESBORUGH AVE.TELEPHONE:
(661) 412-4845
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: DATE:
04/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH:Nemia Ong, LicenseeTIME COMPLETED:
10:55 AM
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On 04/14/22, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing / Component III Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry into the facility. LPA met with Licensee Nemia Ong.

The facility is a 4 bedroom and 2 bathroom home and fire clearance were granted for 6 Non-Ambulatory for a total capacity of 6. There are 6 residents present during this inspection. LPA toured the facility with Licensee. Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available.

Kitchen was toured and observed to have dishes, plates, and utensils. Knives will be kept locked and secure in the kitchen cabinet. Medications will be locked in two cabinets in the kitchen. First aid kit was observed and contained all required items. Cleaning supplies and chemicals observed to be locked under kitchen sink. A fire extinguisher was observed and had a service date of 01/13/22.

Bedrooms were observed to have the required furnishing and are ready for occupancy. LPA observed an extra supply of bed linens. Hot water temperature ranged between 110.4 to 110.6 degrees F. Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching.

Smoke detectors and carbon monoxide were observed to be operational during this inspection. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have required documents.

Component III was conducted during today's pre-licensing visit.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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