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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206698
Report Date: 09/21/2023
Date Signed: 09/21/2023 12:51:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2023 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230623172322
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: 6DATE:
09/21/2023
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Staff, Justin ClemenoTIME COMPLETED:
10:42 AM
ALLEGATION(S):
1
2
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9
Facility staff abandoned resident at the hospital.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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9
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13
Licensing Program Analyst (LPA) Darius Williams conducted an unannounced follow up visit to deliver findings. LPA Williams met with Staff Justin Clemeno and discussed the purpose of the visit. Administrator Susan Baal was contacted via phone and informed of the purpose of the visit.

LPA Williams conducted record reviews and interviews.

According to record review and interviews, Administrator Ulysis Baal and Staff 1 (S1) transported R1 to the hospital emergency room. According to S1, the nurse at the front desk took custody of R1 and informed the Administrator and S1, "They were good to go."

According to SOC341, the hospital was conducting triage on R1.

*Continued on LIC9099C*
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20230623172322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/21/2023
NARRATIVE
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LPA Williams attempted to contact Witness 1, Witness 2, and Witness 3, via phone and e-mail, to clarify statements and regarding R1's admission to the hospital. LPA had not received any return contact from any of the witnesses.

Although the allegation,facility staff abandoned resident at the hospital, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

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: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2