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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209392
Report Date: 03/20/2025
Date Signed: 03/20/2025 04:15:23 PM

Document Has Been Signed on 03/20/2025 04:15 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DIVINE MERCY CARE HOMESFACILITY NUMBER:
157209392
ADMINISTRATOR/
DIRECTOR:		ORILLOSA, NEILFACILITY TYPE:
740
ADDRESS:10239 LANESBOROUGH AVENUETELEPHONE:
(661) 412-4845
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 6DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Designee Virginia Ramos and Administrator Neil Orillosa via telephoneTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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On 03/20/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and requested to meet with Administrator. LPA met with designee Virginia Ramos. Administrator Neil Orillosa was called and stated unable to attend meeting. LPA met with designee Virginia Ramos. LPA observed four residents in the common area. LPA toured facility with designee and staff 2.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Refrigerator and kitchen pantry observed locked. Fire extinguisher was observed with a service date: 09/16/24. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 33 degrees F and freezer at -12 degrees F. Medications were observed locked kitchen shelves. MARS were reviewed and medications were checked. Cleaning supplies and chemicals stored and locked under kitchen sink. Sharps observed locked in kitchen shelf. Extra linens were observed. All bedrooms were observed to have the required furnishings and with adequate lighting. LPA observed to hospice residents lying in bed with full rail. The bathrooms were toured and observed operational during inspection. Hot water temperature was tested at 114 degree F in hall bathroom and 114.1 degree F in shared master bathroom. Outside of facility toured and observed to be free of debris. Adequate outdoor seatings available for clients. Side gate observed self-latching and self-closing. Smoke detectors and carbon monoxide were observed operational during visit. Half of residents’ files and a sample staff file were reviewed to have all required documents.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.

Exit Interview conducted. LPA received copies of Lic 308, Lic 500, Lic 610E, current liability insurance, theft and lost policies and procedure to CCL by 03/26/25. A copy of this report and appeal rights was provided to Administrator, whose signature confirms received of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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 5
Document Has Been Signed on 03/20/2025 04:15 PM - It Cannot Be Edited


Created By: Mai Yang On 03/20/2025 at 03:03 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 CARE HOMES
FACILITY NUMBER: 157209392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observations and records reviewed, R1’s PRN medication Docusate sodium 100 mg and Bisacodyl 10mg was observed and not record R1’s MAR, staff did not record on MAR . R1’s Quetiapine Furamate 25mg/ Seroquel 25mg take 1 tablet by mouth daily recorded on R1’s MAR administered daily, medication not observed in the facility which poses an immediate health and safety risk for the person in care.
POC Due Date: 03/21/2025
Plan of Correction
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Licensee will ensure to record all medications on resident’s MARs. R1’s MAR recording all of resident’s medications will be submitted to the Fresno CCL by POC due date 03/21/25.

Type A
Section Cited
CCR
87465(c)(2)
87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, R1’s medication Quetiapine Fumarate /Seroquel 50mg instruction take on tablet by mouth twice daily record in R1’s MAR administered daily once a day at bedtime which poses an immediate health and safety risk for the person in care.
POC Due Date: 03/21/2025
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation which will include medication is administered as prescribed and medication is record on MAR correctly to Fresno CCL office by POC due date 03/21/25.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/20/2025 04:15 PM - It Cannot Be Edited


Created By: Mai Yang On 03/20/2025 at 03:08 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 CARE HOMES
FACILITY NUMBER: 157209392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, R1 and R2 are on hospice care lying bed using a hospital bed with full rail with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 03/26/2025
Plan of Correction
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Full bed rails are prohibited. Licensee shall obtain doctor orders for R1 and R2 who’s currently receiving hospice care that specific the need for full bed rails and submitted to the Fresno CCL by POC due date 03/26/25.
Type B
Section Cited
CCR
87468(a)(6)
87468(a)(6) To make choices concerning their daily lives in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, refrigerator was locked with a metal chain and food pantry was locked, which poses/posed a potential health and safety and personal rights risk to the resident in care.

POC Due Date: 03/21/2025
Plan of Correction
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Staff immediately unlock food pantry and removed chain prior to facility tour. POC cleared during visit.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/20/2025 04:15 PM - It Cannot Be Edited


Created By: Mai Yang On 03/20/2025 at 03:09 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 CARE HOMES
FACILITY NUMBER: 157209392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
87303(e)(5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews conducted, the licensee did not comply with the section cited above no non-skid mat or strip was observed in the residents’ bathrooms, which poses/posed a potential health, safety or personal rights risk to person in care.
POC Due Date: 03/26/2025
Plan of Correction
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Proof of non-skid mat or strips bathrooms tub/shower shall be submitted to the Fresno CCL by POC due date 03/26/25.
Type B
Section Cited
CCR
87303(a)(1)
87303(a)(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, hall bathroom, mold was observed in the bathroom shower and in bathroom walls which poses/posed a potential Health, Safety, and Personal Rights risk to the resident.
POC Due Date: 04/02/2025
Plan of Correction
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Licensee shall ensure there are no molding in resident’s bathroom shower and wall. Proof shall be submitted to Fresno CCL office by POC due date 04/02/25.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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