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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804175
Report Date: 12/04/2023
Date Signed: 12/04/2023 07:24:26 PM


Document Has Been Signed on 12/04/2023 07:24 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:BUI, MARIAFACILITY TYPE:
740
ADDRESS:105 MAYWOOD DRTELEPHONE:
(707) 334-1709
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 3DATE:
12/04/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Maria Bui, Licensee/AdministratorTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived announced to conduct a Post-Licensing Inspection and to go over a recent Fire clearance for this facility. LPA met with licensee, Maria Bui and went over resident records.

On November 3, 2023 this facility submitted a request for 1 ambulatory and 5 non-ambulatory residents and a new fire clearance was approved by the Vallejo Fire department. The fire clearance is for room #1,2,4 & 5 for non-ambulatory residents and room #3 to be used by ambulatory residents. This facility was previously licensed for all ambulatory residents on 9/26/2023 and received a Hospice waiver for 2 of the residents on 10/4/2023.
Due to the system having issues with the care tool, LPA will need to return to complete inspection and issue citations that were observed on todays date.

During todays inspection LPA observed resident R1 using a walker, in addition, physician report showed resident having Dementia as a secondary diagnoses. Resident was also observed introducing self 2 x's to LPA & Administrator, while sitting in the dining room area and using a fork to eat soup. Resident R2 was admitted 10/17/2023 is on Hospice with a Dementia diagnoses and using a walker and in room #3 which was previously approved for ambulatory only and in the second fire clearance, room #3 continued to only be approved for ambulatory residents. In addition 2 out of 3 residents had a preplacement appraisal just signed, but blank and appraisal needs & service also was blank. Facility also failed to send in Hospice notification to CCL when they received their first Hospice resident.

No citations issued at this time and LPA will return to complete and issue citations warranted. Report emailed to Licensee.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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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