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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209212
Report Date: 02/27/2023
Date Signed: 03/01/2023 08:26:38 AM


Document Has Been Signed on 03/01/2023 08:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:DIVINE MERCY HOME CAREFACILITY NUMBER:
157209212
ADMINISTRATOR:ONG, NEMIA CFACILITY TYPE:
740
ADDRESS:10239 LANESBORUGH AVETELEPHONE:
(661) 412-4845
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 5DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Nemia Ong, LicenseeTIME COMPLETED:
12:45 PM
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On 2/27/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA was greeted my Licensee Nemia Ong. LPA introduced self, stated the purpose of the visit, and was granted entry. All five residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social Distancing signs and cough etiquette postings not observed.

LPA checked residents’ locked medications. LPA observed a small sample of PPE supplies in facility. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked under kitchen sink. LPA observed fire extinguisher served date: 01/11/23.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 3 shared residents’ bed to be at least 6 feet apart. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks. The exterior tour was conducted. Side gate was self-closing and self-latching. All five resident records reviewed to have updated emergency contact information. Staff records were reviewed for good health and infection control training.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 3/6/23. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610D, Lic 9282, current liability insurance and current Administrator certificate. A copy of this report was provided to Licensee.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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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