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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206698
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:06:42 PM

Document Has Been Signed on 03/12/2025 03:06 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DIVINE MERCY GUEST HOME IIIFACILITY NUMBER:
157206698
ADMINISTRATOR/
DIRECTOR:		BAAL, SUSAN & ULYSISFACILITY TYPE:
740
ADDRESS:2301 SCARBOROUGH LANETELEPHONE:
(661) 397-4234
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator: Administrator: Susan BaalTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 3/12/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Myrna Baniaga, LPA was granted entry. 6 residents were present during inspection. Licensees (L1 and L2) Ulysis and Susan Baal arrived shortly after LPA’s arrival.

LPA toured facility with L2. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Samples of resident’s medications were checked and observed locked in kitchen cabinet. Clients’ MARS was reviewed. Fire extinguisher reviewed with a service date of: 3/15/25. Fire drill not completed or logged. Clients' bedrooms were toured and reviewed. Cleaning chemicals were observed stored and locked in cabinet. Residents bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 113.9 to 118.2 degrees in 2 bathrooms. 1 out of 3 faucets did not contain hot running water.

Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature observed at 0 degrees F and refrigerator temperature maintained at 40 degrees F. Smoke detectors and carbon monoxide were tested and observed to be operational. All clients’ files and staff’s files reviewed. 2 out of 2 staff did not contain updated First Aide. First Aide kit observed to have all of the required items.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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Document Has Been Signed on 03/12/2025 03:06 PM - It Cannot Be Edited


Created By: Jacques Leffall On 03/12/2025 at 02:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME III
FACILITY NUMBER: 157206698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above in 1 out of 3 bathroom faucets did not contain hot water, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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Licensee agrees to repair water faucet to have hot running water. Licensee agrees to submit written documentation of purchase or invoice, and photo of temperature of water ranging from 105-120 degrees F to CCLD by POC due date.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 staff's FIrst Aide expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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Licensee agrees to have staff complete First Aide training and submit copies of updated First AIde Cards to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/12/2025 03:06 PM - It Cannot Be Edited


Created By: Jacques Leffall On 03/12/2025 at 02:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIVINE MERCY GUEST HOME III
FACILITY NUMBER: 157206698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87212(b)(2)(A)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (2) Plan for evacuation including: (A) Fire safety plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 fire drill was not completed and logged, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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Licensee agrees to conduct quarterly fire drills and submit copies of the Fire Drill log of updated fire drill to CCLD by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: DIVINE MERCY GUEST HOME III
FACILITY NUMBER: 157206698
VISIT DATE: 03/12/2025
NARRATIVE
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The following deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 3/26/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance-RCFE, Emergency and Disaster Plan LIC 610E -, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020A-

A copy of this report and appeal rights was provided to L1, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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