<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206698
Report Date: 05/18/2023
Date Signed: 05/30/2023 01:05:23 PM

Document Has Been Signed on 05/30/2023 01:05 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: 5DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Admininstrator Susan and Ulysis Baal.TIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Darius Williams conducted an unannounced annual inspection visit. LPA Williams met with Administrator Susan and Ulysis Baal, and discussed the purpose of the visit.

LPA and the Administrator toured the facility.

The kitchen was clean and in good repair. Medications were observed behind a locked cabinet inaccessible to residents. Refrigerator temperature reflected 40 degrees Fahrenheit (F) and freezer reflected 0 degrees F. Water temperature reflected approximately 116.1 degrees F.

Dining room and living room were clean and in good repair. There was seating present to accommodate all residents.

The hallway closet housed extra linens for residents.

The LPA toured four bedrooms. All bedrooms had beds, required linens, chair, dresser, night stand, lamp, and space to accommodate residents.

The LPA toured two bathrooms. Both bathrooms had non-slip mats and grab bars to assist residents as needed.

The backyard space had a covered patio to keep residents out of the elements, and seating to accommodate. There is no pool on the premises.

*Continued on LIC 809-C*
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 157206698
VISIT DATE: 05/18/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Smoke detectors, carbon monoxide, and fire extinguisher were present and operational.

LPA Williams reviewed 5 resident files. LPA reviewed Admission agreement and observed an addendum regarding refund policies. LPA Williams discussed with the Administrator changes to the policy to bring it in line with the California Health and Safety Code.

No deficiencies were cited during this visit.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2