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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209392
Report Date: 03/26/2024
Date Signed: 03/28/2024 09:16:05 AM

Document Has Been Signed on 03/28/2024 09:16 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DIVINE MERCY CARE HOMESFACILITY NUMBER:
157209392
ADMINISTRATOR:ORILLOSA, NEILFACILITY TYPE:
740
ADDRESS:10239 LANESBOROUGH AVENUETELEPHONE:
(661) 412-4845
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 6DATE:
03/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Neil Orillosa, LicenseeTIME COMPLETED:
12:00 PM
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On 03/26/24, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing and
Component III inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the
facility. LPA met with Neil Orillosa, Licensee.

The facility is 3 bedroom and 2 bathroom home. Fire clearance was granted for 4 Non-Ambulatory and 2
bedridden for total of 6 capacity. All six residents were present during this inspection. LPA toured the facility with Licensee. Facility temperature is set to 74 degrees F. Common areas were furnished and had adequate seating and lighting available. A fire extinguisher was observed and has a service date of 01/19/24. LPA observed a 2-day supply of perishable foods and a 7 day supply of non-perishable foods.Knives were observed to be locked and secured in kitchen shelf. Medications were kept locked and inaccessible to residents in care in kitchen shelves. First aid kit was observed and contained all required items. Kitchen was toured and observed to have dishes, plate, and utensils. Refrigerator temperature maintained at 40 degrees F and freezer temperature at 0-degree F. Cleaning supplies and chemicals were observed locked under kitchen sink. Washer and dryer observed operational during inspection. LPA observed an extra supply of bed linens and personal hygiene products. Bedrooms were observed to have required furnishings. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water measured range between 115.7 degrees F and 115.3 in shared master bathroom and 111.7 degrees F in bathroom. Outside of facility toured. Exterior toured and LPA observed side gate to be self-closing and self-latching. Outdoor seatings observed available for residents. Sample of residents and staff records were reviewed and observed to have required documents. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection.

Component III was conducted during today's pre-licensing visit. I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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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