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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206698
Report Date: 04/15/2026
Date Signed: 04/15/2026 01:15:46 PM

Document Has Been Signed on 04/15/2026 01:15 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: 4DATE:
04/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Ulysis BaalTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) J. Duarte arrived at the facility unannounced to conduct an Annual Inspection. LPA was greeted and granted entry by staff. Saff contacted Administrator Ulysis Baal and he arrived shortly after. Staff reported that the facility has four residents and all residents were present.

The facility was observed to be at a temperature of 73 degrees F, clean with no passageway obstructions. The living room has sufficient seating for residents. The kitchen was toured and LPA observed a two-day supply of perishable and seven-day supply of non-perishable food. The facility stores sharps in a locked kitchen cabinet. Medication is kept secured in a locked kitchen cabinet. A fire extinguisher was observed in the kitchen, with a service date of 06/05/2025. A complete first Aid Kit was observed secured to the wall next to the kitchen.

All bedrooms were toured and observed to have the required furniture and adequate lighting. Restrooms were equipped with grab bars in the shower and next to the toilet, non-slip mats were observed in the showers. The hot water temperature in the restrooms was tested and measured between 107 and 110 degrees F.

The facility has a dryer and washer in the garage. Chemicals and detergent were observed locked in cabinet. Outside of the facility was toured and observed to be free of debris. The facility has a back patio with seating available. LPA observed the facility sketch reflects Gate #2, that exits towards Sutton Place, has been removed and there is only a fence with no gate. The exterior has an additional exit, Gate #1, that exits towards Scarborough Lane. Gate #1 remains in place and functioning.

Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/15/2026 01:15 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 04/15/2026 at 12:39 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: 04/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

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 that the facility sketch reflects Gate #2, that exits towards Sutton Place, has been removed and there is only a fence with no gate. The exterior has an additional exit, Gate #1, that exits towards Scarborough Lane. Gate #1 remains in place and functioning. Administrator stated that Gate #2 was cancelled about six months ago,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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Administrator stated that an updated facilty sketch will be submitted to CCLD by POC due date to reflect the removal of Gate #2.
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.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2026


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: 04/15/2026
NARRATIVE
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Continued from LIC 809.

The carbon monoxide/smoke detectors were observed operational during inspection. The last fire drill was conducted on 04/11/2026, per staff records. Resident files and a sample of staff files were reviewed and observed to have required documentation. Medications were reviewed along with MARS.

Deficiencies are being cited on the attached LIC 809-D page. Plan of corrections was reviewed and discussed with the administrator.



An exit Interview was conducted. A copy of this report and appeal rights were provided to the administrator, whose signature on this form confirms receipt of this report.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 04/22/2026
NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC809 (FAS) - (06/04)
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