<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804175
Report Date: 01/24/2025
Date Signed: 01/24/2025 06:14:32 PM

Document Has Been Signed on 01/24/2025 06:14 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DIVINE MERCY FAMILY HOMEFACILITY NUMBER:
486804175
ADMINISTRATOR/
DIRECTOR:		BUI, MARIAFACILITY TYPE:
740
ADDRESS:105 MAYWOOD DRTELEPHONE:
(707) 334-1709
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
01/24/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:19 PM
MET WITH:Lito Francisco, caregiverTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Araceli Canela arrived unannounced and met with caregiver, Lito Francisco and toured the home.

During the course of a complaint investigation, LPA discovered the facility is using a small metal stick that is jammed sideways on the door frame, through a small opening that was made in order to use it as a locking mechanism. LPA was attempting to open the exit door, the door was stuck and would not open. Staff then explained they needed to remove the stick. LPA was not aware of the stick because there was a small sign in front that prevented its view. LPA asked why they were using a stick to block the door from opening and staff explained that it was due to the resident that is occupying the room, has memory issues and tries to exit and for their safety they prevent the door from opening. Resident R1 Physicians report LIC602 states R1 has wondering behaviors and sun downing. Resident first diagnoses is not Dementia but report states memory loss.
LPA explained to administrator/licensee Maria Bui that they may not lock any exit doors and that they need to ensure the safety of the resident. LPA also explained that facility is not doing preplacement appraisals and these need to be conducted so that the facility can ensure they can meet the residents needs or if they need to have more staff present for the safety of elopement instead of using a locking mechanism to prevent the exit door from opening.
LPA explained to staff that the tall dresser in the staff room has to be moved to allow the door to open enough for residents in wheelchairs/walkers to use, as their room has an exit door that is identified by the fire department as exit. LPA also advised administrator the facility does not have bedridden approval from our department.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted, report and appeal of rights emailed.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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 2
Document Has Been Signed on 01/24/2025 06:14 PM - It Cannot Be Edited


Created By: Araceli Canela On 01/24/2025 at 02:38 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DIVINE MERCY FAMILY HOME
FACILITY NUMBER: 486804175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/25/2025
Section Cited
CCR
87203

1
2
3
4
5
6
7
87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
1
2
3
4
5
6
7
Facility to send in written plan that they understand regulation and how they will ensure staff supervision/alarms is used for resident who may wonder away, instead of blocking an exit door.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: during to days visit LPA observed a small metal stick that was jammed to the door frame to prevent it from opening. This is an immediate Risk to the health & safety of residents in care.
8
9
10
11
12
13
14
POC due by 1/25/2025.

Civil penalty is being applied for $500.00 for Fire safety violation

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2