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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804175
Report Date: 09/11/2023
Date Signed: 09/11/2023 04:06:05 PM


Document Has Been Signed on 09/11/2023 04:06 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:DIVINE MERCY FAMILY HOMEFACILITY NUMBER:
486804175
ADMINISTRATOR:BERNARDINO, KRISTINEFACILITY TYPE:
740
ADDRESS:105 MAYWOOD DRTELEPHONE:
(707) 334-1709
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 0DATE:
09/11/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Maria BuiTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, Maria Bui. Applicant has applied for a Change of Location of an existing Residential Care for the Elderly Facility.

Facility is a one story residence with five bedrooms that will be used by residents, one staff bedroom, one office, two bathrooms & common areas. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Bathroom tub showers have non-skid floor mats and grab bars. Water temperature read at 107 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items for cooking & eating. Centrally stored medications, staff and resident records will be locked in the office. Cleaning supplies & toxins are locked in a cabinet under the kitchen sink and in a cabinet in the garage. Non-perishable foods are available and perishable foods will acquired as soon as the facility gets their 1st resident and will be stored per regulation. Facility has areas inside and outside for visiting and activities. Posting requirements observed, PUB 475 poster needs correct size of 20x26.

Facility received an approved fire clearance dated June 29, 2023 that allows for up to six ambulatory Only and no non-ambulatory or bedridden residents. Facility will not accept Dementia care residents or has an approval to care for Hospice residents until they can receive a fire clearance and approval from the fire department and licensing for Non-ambulatory residents. Facility has combination Smoke/Carbon Monoxide detectors that were tested and operational during inspection.

LPA will email Applicant information on how to sign up for the Guardian. Component III was conducted with Applicant. Other than the applicant needing proof of a current Administrator Certificate, "Pre-Licensing is complete and this facility has no deficiencies.

LPA will notify Application Unit so application process may proceed and acquire proof of Liability Insurance and Administrator Certificate.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023
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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