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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206576
Report Date: 07/22/2025
Date Signed: 07/22/2025 03:44:54 PM

Document Has Been Signed on 07/22/2025 03:44 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DIVINE MERCY GUEST HOME IIFACILITY NUMBER:
157206576
ADMINISTRATOR/
DIRECTOR:		BAAL, SUSAN H.FACILITY TYPE:
740
ADDRESS:809 HEWLETT STREETTELEPHONE:
(661) 374-4600
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 6DATE:
07/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Ulysis BaalTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 07/22/2025 , Licensing Program Analysts (LPA) J. Duarte arrived unannounced at the facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry into the facility by staff Juliana Canonero. LPA J. Duarte contacted Administrator (AD), Susan Baal who stated she would arrive shortly. Administrator Ulysis Baal arrived shortly after LPA contacted Susan. Susan arrived shortly after Ulysis arrived.

LPA toured the inside and outside of the facility with AD Ulysis. The facility was observed to be clean, odor free and at a temperature of 78 degrees F. The pathways and doors were clear and free from obstructions. Common areas were clean, adequately furnished, and adequately lit. . LPA observed sufficient seating in the living room. The Kitchen and dining areas were clean and had sufficient seating. LPA observed a seven-day supply of non-perishable foods and two-day supply of perishable foods. However, there were multiple food items in the refrigerator that were expired and/or spoiled and there were also food in containers in the refrigerator that were not labeled. LPA observed unlocked staff medication in a kitchen cabinet and in the entry office. Knives were also observed to be unlocked in a kitchen cabinet.



LPA toured the residents’ rooms. Two rooms are single occupancy and two are shared. Resident rooms were observed to have the required furnishings. The bathroom hot water measured at 105.4 degrees F. Bathrooms were equipped with grab bars next to the toilet and in the shower, and the showers had non-skid mats. LPA observed bleach unlocked in a cabinet in the hallway bathroom. Medication and MARS were reviewed for two residents and logs were observed to be complete.

Report Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/22/2025 03:44 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 07/22/2025 at 01:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME II
FACILITY NUMBER: 157206576

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:

Based on observation, the licensee did not comply with the section cited above in that knives in the kitchen cabinet and disinfectants in the hallway restroom were observed unlocked,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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Admininstrator immediately locked the restroom cabinet that contained the bleach and also locked the kitchen knives with a key lock.
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:

Based on observation the licensee did not comply with the section cited above in that staff medication was observed unlocked in a kitchen cabinet and also in the office area. In addition, resident medication is stored in small fridge in the living room. The fridge was observed to be unlocked. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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Administrator placed staff medication in a locked cabinet. Administrator Ulysis locked the resident medication fridge.
Administrators Susan and Ulyis stated that they will receive medical training for themselves and staff in the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/22/2025 03:44 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 07/22/2025 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME II
FACILITY NUMBER: 157206576

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)


This requirement is not met as evidenced by:
Deficient Practice Statement
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(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:

Based on observation, multiple food was observed to be expired and/or spoiled,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2025
Plan of Correction
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Administrator immediately disposed of the expired and/or spoiled food.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: DIVINE MERCY GUEST HOME II
FACILITY NUMBER: 157206576
VISIT DATE: 07/22/2025
NARRATIVE
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Continued from LIC 809

Laundry area toured in the garage. LPA observed a locked closet in the garage that has all chemicals. The backyard was observed to have sufficient seating in the back patio. LPA observed a fenced pool in the backyard with a locked gate. Outdoor side gate is self-closing and self-latching.

Smoke detectors and carbon monoxide detectors were present and operational at the time of visit. The fire extinguisher located in the kitchen was last serviced on 06/05/2025. A fire drill was conducted on 06/25/25, per staff records.

Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6 on the attached LIC 809D.

LPA requested the following documents to be submitted to CCL by 07/28/2025: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) to update the facility file.

An exit interview was conducted, and a plan of correction was reviewed and developed with the administrators. A copy of this report and appeal rights were discussed and provided to the Administrator, whose signature on this form
NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC809 (FAS) - (06/04)
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