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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206698
Report Date: 07/14/2022
Date Signed: 07/14/2022 10:03:05 AM

Document Has Been Signed on 07/14/2022 10:03 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:
07/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Susan Baal, Licensee
Ulysis Baal, Licensee		TIME COMPLETED:
10:15 AM
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On 7/14/22 at 9:10 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - incident inspection. LPA called Licensee (LIC) Susan Baal and explained reason for inspection. LIC arrived a short time later and granted entry.

CCL received a Special Incident Report (SIR) for an incident that occurred on 1/14/22 concerning R1 and S1. LPA conducted interviews and reviewed records.

No deficiencies cited during this inspection.

Exit interview conducted. A copy of this report was given to Licensee Susan Baal, whose signature confirms receipt of this report.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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