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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206697
Report Date: 03/12/2025
Date Signed: 03/12/2025 05:23:42 PM

Document Has Been Signed on 03/12/2025 05:23 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 IVFACILITY NUMBER:
157206697
ADMINISTRATOR/
DIRECTOR:		BAAL, SUSAN H.FACILITY TYPE:
740
ADDRESS:704 HEWLETT STREETTELEPHONE:
(661) 321-0144
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 4DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Licensees Ulysis and Susan BaalTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
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On 3/12/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Licensee (L1) Susan Baal, LPA was granted entry. 4 residents were present during inspection.

LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Samples of resident’s medications were checked and observed locked in kitchen cabinet. Clients’ MARS was reviewed. Fire extinguisher reviewed with a service date of: 3/15/25. Fire drill completed on 12/20/24. Clients' bedrooms were toured and reviewed. Cleaning chemicals were observed stored and locked in closet. Residents bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 106.7 to 108.5 degrees in 2 bathrooms.

Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature observed at 0 degrees F and refrigerator temperature maintained at 32 degrees F. Smoke detectors and carbon monoxide were tested and observed to be operational. All clients’ files and staff’s files reviewed to have all of the required documents. First Aide kit observed to have all of the required items.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: DIVINE MERCY GUEST HOME IV
FACILITY NUMBER: 157206697
VISIT DATE: 03/12/2025
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No deficiencies issued during this inspection.

Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 3/26/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A)

A copy of this report was provided to L1, whose signature on this form confirms receipt of these report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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