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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206576
Report Date: 01/31/2022
Date Signed: 01/31/2022 07:08:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2022 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220131091233
FACILITY NAME:DIVINE MERCY GUEST HOME IIFACILITY NUMBER:
157206576
ADMINISTRATOR:BAAL, SUSAN H.FACILITY TYPE:
740
ADDRESS:809 HEWLETT STREETTELEPHONE:
(661) 374-4600
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:6CENSUS: 4DATE:
01/31/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Susan Baal, Licensee/Administrator
Ulysis Baal, Licensee		TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Illegal Eviction.
INVESTIGATION FINDINGS:
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On 1/31/22 at 12:55 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an initial 10-day complaint inspection. LPA explained reason for inspection and was granted entry. Licensee (LIC) Susan Baal and Licensee Ulysis Baal arrived a short time later.

LPA conducted interviews and reviewed records. Based on interviews and records reviewed, LPA found that LIC did not issue proper eviction notice to R1. R1 was admitted to the hospital and upon hospital discharge, LIC admitted to refusing R1's return to the facility because R1 was positive for COVID-19 and did not want to infect the other residents. Facility submitted an approved mitigation plan LIC808 to CCL on 2/25/21. Therefore, the above allegation is substantiated.

A deficiency is being cited based on LPA observation, interviews conducted, and records review in accordance with the California Code of Regulations, Title 22, see LIC9909D.
***Continue on LIC9099C.***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20220131091233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: DIVINE MERCY GUEST HOME II
FACILITY NUMBER: 157206576
VISIT DATE: 01/31/2022
NARRATIVE
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***Continued from LIC9099.***

An exit interview was conducted. Due to COVID-19 precautionary precautions, this report and appeal rights will be emailed to the email on record with "Read receipt" to confirm receipt of this report. LPA verified with LIC that the email on record is current.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 24-AS-20220131091233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME II
FACILITY NUMBER: 157206576
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2022
Section Cited
CCR
87224(d)
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87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.

This requirement is not met as evidenced by:
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Licensee will submit proof of in-service training of mitigation plan LIC808 review for both Licensees to CCL by POC due date.
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LPA found that LIC did not issue proper eviction notice to R1. R1 was admitted to the hospital and upon hospital discharge, LIC admitted to refusing R1's return to the facility because R1 was positive for COVID-19 and did not want to infect the other residents. Facility submitted an approved mitigation plan to CCL on 2/25/21. This poses a potential personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3