Divine Mercy Family Home

Allegation investigated: Facility was found to be unsanitary Facility did not provide resident with adequate hygiene and personal care Facility has rodents

At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with House Manager Venus Stanford, toured the facility and reviewed records. During the course of this investigation LPA observed the facility to be clean and in good repair. On 03/24/2026, the Department was notified of a change of ownership for the building. At that time, the new owner, Venus Stanford, began making improvements to the facility. The facility did have evidence of rodent activity and a pest control company was contacted to address the problem. LPA received copies of invoices of pest prevention. During the investigation, LPA observed there were times when certain areas of the facility did not have a pleasant smell. LPA learned the reasons were due to recent incontinence, which was addressed by facility staff, but the smell lingered. LPA inspected the resident rooms and food storage areas and found them to be clean and food was stored properly. Based on interviews conducted, staff assist residents with hygiene needs and personal care as needed. LPA was not able to find evidence to support the allegation that care was not provided. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 10, 2026 · control 21-AS-20260414150016

Type of visit: Required - 1 Year

At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with House Manager Venus Stanford and explained the purpose of the visit. Facility does not currently have an Administrator with a valid certificate. Venus has completed the training and is waiting on her Certificate. Facility has a Hospice waiver for 2 residents. At approximately 9:20AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen equipment was clean and in good repair. Dishware appeared to be stored in a sanitary manner. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature. Facility has required supply of perishable and non-perishable food. Emergency water was present to ensure facility can be self-sufficient for 72 hours. Emergency lighting devices were present. First aid kit was present. No pools/bodies of water are on the premises. Facility has been conducting Emergency drills monthly. At approximately 10:00AM, LPA reviewed 4 of 4 resident files. 2 of 4 resident files contained reappraisals that were conducted within the last 12 months. Documentation of a physician visit within the last 12 months was present. At approximately 12:00PM, LPA reviewed medication records. Due to time constraints, LPA will return at a later date to complete this inspection.the state’s words, verbatim · CDSS document, Jul 10, 2026

Type of visit: Case Management - Other

At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to open a complaint investigation. LPA met with Venus Stanford. During this investigation, LPA observed there were several metal bars that were inserted into a hole in the door jam and protruding into the wood of the door, preventing the door from opening. LPA observed the metal bars were on a residents exit door, the front door and rear exit door of the facility. The metal bar in the residents exit door was located at the top of the door jam. LPA requested staff to remove the bar, but it was located higher than they could reach. All metal bars have been removed from doors. LPA requested the holes be filled to prevent the use of the metal bars in the future. This is an Immediate Safety risk to residents in care and am immediate civil penalty is being issued in the amount of $500. LPA was informed on March 24, 2026 that there was a change in ownership of this business. The letter stated the change took place on March 1, 2026. The Department was not notified within the timelines provided in regulation. On 03/25/2026, LPA requested the written notifications made by the Licensee to the families and LPA has not received copies. On 04/06/2026, LPA received an Unusual incident report regarding resident, R1, eloping from the facility on 03/25/2026. Staff went to the room to wake R1 and found they were not in the room. Staff searched the surrounding area and notified the responsible party. Law Enforcement was notified. R1 was found at approximately 1:00PM the same day, in a parked vehicle in the neighborhood. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Venus Stanford and Appeal rights were given.the state’s words, verbatim · CDSS document, Apr 20, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Apr 21, 2026

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. This requirement is not met as evidenced by: Based on observation, LPA found metal rods placed between the door and the door jam of an emergency exit, preventing the door from opening. This poses an Immediate Safety risk to persons in care. An immediate civil penalty is being issued in the amount of $500.the state’s words, verbatim · CDSS document, Apr 20, 2026

Plan of correction: All metal rods were removed. Violation cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(5)(a) · Plan of correction due date: May 8, 2026

87224 Eviction Procedures: (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not provide at least a 60 day written notice to residents or responsible parties regarding the change of ownership of the facility. This poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 20, 2026

Plan of correction: Licensee sent notices to residents and responsible parties. Cleared during visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Apr 21, 2026

(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure the exit door alarm was operational and loud enough for staff to be aware of resident leaving. This poses an Immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 20, 2026

Plan of correction: Licensee replaced audiable alerts on exit doors. Cleared during visit.

Type of visit: Case Management - Annual Continuation

At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to continue a Required-1 Year inspection. LPA met with Administrator Maria Bui and reviewed Staff and Resident records. At approximately 9:30AM, LPA reviewed 5 of 5 resident files. 3 of 5 resident appraisals were not completed within the last 12 months. 1 of 5 physician reports was not completed within the last 12 months and there was no documentation of a refusal. At approximately 10:00AM, LPA conducted a review of medications. Medication is locked and not accessible. LPA observed medication was prepared several days in advance. LPA discussed regulation regarding transferring medication between containers. At approximately 10:30AM, LPA reviewed 6 staff files. Staff files reviewed did not contain current evidence of completed annual training in 5 of the 6 files. First Aid/CPR certification was current. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Evidence of control of Property, (Current Rental/Lease Agreement/Deed) LIC500- Personnel Report LIC308- Designation of Facility Responsibility LIC610E- Disaster Plan Evidence of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator and Appeal rights were given.the state’s words, verbatim · CDSS document, Aug 26, 2025

Allegation investigated: Personal rights

At approximately 11:50AM, Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced and met with Maria Bui to deliver findings of a complaint investigation-initiated January 22, 2025. During the course of this investigation, outside records were reviewed, observations made, and interviews conducted. Complaint alleges a personal rights violation due to a bruise and an open wound on the side of Resident (R1)’s) face. During the course of the investigation, the Department reviewed records, including hospital records, home health records and facility records. In addition, the Department conducted several interviews with Home Health staff, R1’s responsible party and facility staff. Based on information received during the investigation, the following was determined: R1 was seen by their PCP on 1/15/25 with no bruising/wound on their face. On 1/16/25, facility notified home health of a bruise on R1’s face. On 1/17/25, home health nurse observed bruise and wound on R1’s face. R1 had no recollection of a fall and denied pain. Facility denied that R1 had a fall. A review of R1’s hospital records state “Head skin lesion (the right cheek and right temple bruising) was likely due to R1 leaning their head onto railing. Continued on LIC9099-C... Unsubstantiated No signs of trauma.” Based on a review of the evidence, the face wound could not be attributed to a fall by R1. It is possible from R1 leaning on gurney railing during transport back to facility as PCP saw R1 on 01/15/2025 with no bruising or abrasions on the face and facility staff noted the area on R1’s return from their PCP appointment”. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation personal rights is unsubstantiated.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 21-AS-20250122095345

Type of visit: Required - 1 Year

At approximately 11:50AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Maria Bui and explained the purpose of the visit. Administrator certificate is expired but the renewal packet has been submitted. Facility has a Hospice waiver for 2 residents. At approximately 12:15PM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. The water temperature measured above regulation at faucets accessible to residents. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen equipment was clean and in good repair. Dishware appeared to be stored in a sanitary manner. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature. Facility has required seven-day non-perishable and two-day perishable supply of food. Emergency food stores and water was present to ensure facility can be self-sufficient for 72 hours. Emergency lighting devices were present. First aid kit was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has been conducting Emergency drills every 3 months. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Maria Bui and Appeal rights were given.the state’s words, verbatim · CDSS document, Jul 29, 2025

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Jan 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jan 25, 2025

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. 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.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: 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. POC due by 1/25/2025. Civil penalty is being applied for $500.00 for Fire safety violation

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Araceli Canela arrived at Divine Mercy Family Home, unannounced for the purpose of conducting a Required-1 year inspection. LPA met with Care staff, Jason Orot; Licensee/Administrator, Maria Bui was not present at the facility but available by phone. This facility is licensed for 5 non-ambulatory residents, 1 ambulatory resident, no approval for bedridden and a Hospice Waiver for 2 of the residents. LPA toured the home and found the home at a comfortable temperature with all exits free from obstruction. There are a total of seven bedrooms (5 used by residents, room #3 for ambulatory only, 1 staff room split in half and an office), 2 bathrooms, living room, dining room, kitchen and garage. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher was observed charged & serviced August 7, 2024. Water temperature in the resident bathroom was found to be at 107 and within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in key locked cabinets. There was a 7 day supply of perishable foods and sufficient amount of nonperishable foods. There are adequate dishes, glasses and silverware. LPA reviewed staff files and staff have the required training and proof of CPR/1st aid. All 5 resident files were reviewed and 2 of 5 resident files did not have a preplacement appraisal. Resident R1 is using room 3 which is to be used only by ambulatory residents and R1 has a Dementia diagnoses but on the physician medical assessment conducted on 4/10/2024, the physician marked it as ambulatory. A previous medical assessment for R1 conducted on 4/20/2023 the physician marked as non-ambulatory. LPA called and spoke with doctor for the report done on 4/10/2024 and the physician stated they completed the form and made a mistake, R1 is non-ambulatory and their report will need to be amended. LPA did not issue a citation, but issued an advisory note and explained to facility that R1 needs to be moved today, to the available room that is non-ambulatory. Continue report see LIC809-C LPA explained to administrator that she needs to review reports and get clarification when there is a doubt. LPA had previously explained to Administrator that dementia diagnoses is always marked as non-ambulatory by the physician as Dementia residents need assistance exiting the facility in case of an emergency because of their diagnoses. Administrators certificate for Maria Bui, #6035927740 expires 7/15/2025. LPA went over S1 who has a fingerprint clearance and does not need an exclusion but requires administrator to follow up to process any paperwork needed to correct the transfer. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Current Lease Agreement LIC500- Personnel Report LIC9020 Resident Roster LIC308 Designation of responsibility. LPA informed care staff, that due to technical issues and half of the tool kit that was answered, had lost half the answers and LPAs time restraint, LPA will need to return to complete visit and issue citations warranted. No citations issued at this timethe state’s words, verbatim · CDSS document, Sep 23, 2024

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Araceli Canela arrived announced to conduct a Post-Licensing Inspection and to go over a recent Fire clearance for this facility. LPA met with licensee, Maria Bui and went over resident records. On November 3, 2023 this facility submitted a request for 1 ambulatory and 5 non-ambulatory residents and a new fire clearance was approved by the Vallejo Fire department. The fire clearance is for room #1,2,4 & 5 for non-ambulatory residents and room #3 to be used by ambulatory residents. This facility was previously licensed for all ambulatory residents on 9/26/2023 and received a Hospice waiver for 2 of the residents on 10/4/2023. Due to the system having issues with the care tool, LPA will need to return to complete inspection and issue citations that were observed on todays date. During todays inspection LPA observed resident R1 using a walker, in addition, physician report showed resident having Dementia as a secondary diagnoses. Resident was also observed introducing self 2 x's to LPA & Administrator, while sitting in the dining room area and using a fork to eat soup. Resident R2 was admitted 10/17/2023 is on Hospice with a Dementia diagnoses and using a walker and in room #3 which was previously approved for ambulatory only and in the second fire clearance, room #3 continued to only be approved for ambulatory residents. In addition 2 out of 3 residents had a preplacement appraisal just signed, but blank and appraisal needs & service also was blank. Facility also failed to send in Hospice notification to CCL when they received their first Hospice resident. No citations issued at this time and LPA will return to complete and issue citations warranted. Report emailed to Licensee.the state’s words, verbatim · CDSS document, Dec 4, 2023