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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206698
Report Date: 05/17/2022
Date Signed: 05/17/2022 09:26:30 AM

Document Has Been Signed on 05/17/2022 09:26 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, 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: 5DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:John Kevin Clemeno, CaregiverTIME COMPLETED:
09:35 AM
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On 5/17/22 at 9:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other. LPA explained reason for inspection and was granted entry by staff. Licensee (LIC) Susan Baal was contacted via telephone and advised she would not be able to come to the facility due to other scheduled appointment. LIC granted permission for staff to sign today's inspection report.

LPA returned resident (R1) and staff (S1) file obtained on 5/12/22 by LPA Lisa Salazar.

No deficiencies cited during inspection.

Exit interview conducted. A copy of this report was provided to caregiver John Clemeno, whose signature confirms receipt of this report.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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