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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206698
Report Date: 05/12/2022
Date Signed: 05/13/2022 02:27:33 PM

Document Has Been Signed on 05/13/2022 02:27 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DIVINE MERCY GUEST HOME IIIFACILITY NUMBER:
157206698
ADMINISTRATOR:BAAL, SUSAN & ULYSISFACILITY TYPE:
740
ADDRESS:2301 SCARBOROUGH LANETELEPHONE:
(661) 397-4234
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Licensees Susan and Ulysis BaalTIME COMPLETED:
12:00 PM
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On 05/12/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a Health & Safety inspection. LPA was greeted by licensee Ulysis Baal, stated purpose of the visit and was allowed entry into the facility.

LPA toured the facility inside and out. LPA observed a 4 bedroom 2 bathroom house . LPA observed 4 out of 4 residents in care. LPA observed a 2 day supply of perishables and 7 day supply of non-perishable foods. Medications and chemicals were observed in locked cabinets in the kitchen.

LPA obtained the files for Resident R1 and Staff S1 review and copying purposes and will return the files within 3 business days.

Exit interview conducted. No deficiencies cited on todays inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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