486804175-9-24-2024-21-AS-ACAA-D9ELUU-20240924090428

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804175
Report Date: 09/23/2024
Date Signed: 09/24/2024 09:06:02 AM

Document Has Been Signed on 09/24/2024 09:06 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	DIVINE MERCY FAMILY HOME		FACILITY NUMBER:	486804175
ADMINISTRATOR:	BUI, MARIA		FACILITY TYPE:	740
ADDRESS:	105 MAYWOOD DR		TELEPHONE:	(707) 334-1709
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	09/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:36 PM
MET WITH:	Jason Orot, care giver		TIME COMPLETED:	04:42 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Araceli Canela arrived at Divine Mercy Family Home, unannounced for the purpose of conducting a Required-1 year inspection. LPA met with Care staff, Jason Orot; Licensee/Administrator, Maria Bui was not present at the facility but available by phone. This facility is licensed for 5 non-ambulatory residents, 1 ambulatory resident, no approval for bedridden and a Hospice Waiver for 2 of the residents. LPA toured the home and found the home at a comfortable temperature with all exits free from obstruction. There are a total of seven bedrooms (5 used by residents, room #3 for ambulatory only, 1 staff room split in half and an office), 2 bathrooms, living room, dining room, kitchen and garage. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher was observed charged & serviced August 7, 2024. Water temperature in the resident bathroom was found to be at 107 and within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in key locked cabinets. There was a 7 day supply of perishable foods and sufficient amount of nonperishable foods. There are adequate dishes, glasses and silverware. LPA reviewed staff files and staff have the required training and proof of CPR/1st aid. All 5 resident files were reviewed and 2 of 5 resident files did not have a preplacement appraisal. Resident R1 is using room 3 which is to be used only by ambulatory residents and R1 has a Dementia diagnoses but on the physician medical assessment conducted on 4/10/2024, the physician marked it as ambulatory. A previous medical assessment for R1 conducted on 4/20/2023 the physician marked as non-ambulatory. LPA called and spoke with doctor for the report done on 4/10/2024 and the physician stated they completed the form and made a mistake, R1 is non-ambulatory and their report will need to be amended. LPA did not issue a citation, but issued an advisory note and explained to facility that R1 needs to be moved today, to the available room that is non-ambulatory. Continue report see LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 486804175
	VISIT DATE: 09/23/2024

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LPA explained to administrator that she needs to review reports and get clarification when there is a doubt. LPA had previously explained to Administrator that dementia diagnoses is always marked as non-ambulatory by the physician as Dementia residents need assistance exiting the facility in case of an emergency because of their diagnoses.

Administrators certificate for Maria Bui, #6035927740 expires 7/15/2025.
LPA went over S1 who has a fingerprint clearance and does not need an exclusion but requires administrator to follow up to process any paperwork needed to correct the transfer.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
Current Lease Agreement
LIC500- Personnel Report
LIC9020 Resident Roster
LIC308 Designation of responsibility.

LPA informed care staff, that due to technical issues and half of the tool kit that was answered, had lost half the answers and LPAs time restraint, LPA will need to return to complete visit and issue citations warranted.

No citations issued at this time

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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