Divine Mercy Guest Home III

Type of visit: Required - 1 Year

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. 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: 04/22/2026the state’s words, verbatim · CDSS document, Apr 15, 2026

Type of visit: Required - 1 Year

On 3/12/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Myrna Baniaga, LPA was granted entry. 6 residents were present during inspection. Licensees (L1 and L2) Ulysis and Susan Baal arrived shortly after LPA’s arrival. LPA toured facility with L2. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Samples of resident’s medications were checked and observed locked in kitchen cabinet. Clients’ MARS was reviewed. Fire extinguisher reviewed with a service date of: 3/15/25. Fire drill not completed or logged. Clients' bedrooms were toured and reviewed. Cleaning chemicals were observed stored and locked in cabinet. Residents bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 113.9 to 118.2 degrees in 2 bathrooms. 1 out of 3 faucets did not contain hot running water. Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature observed at 0 degrees F and refrigerator temperature maintained at 40 degrees F. Smoke detectors and carbon monoxide were tested and observed to be operational. All clients’ files and staff’s files reviewed. 2 out of 2 staff did not contain updated First Aide. First Aide kit observed to have all of the required items. The following deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 3/26/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance-RCFE, Emergency and Disaster Plan LIC 610E -, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020A- A copy of this report and appeal rights was provided to L1, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Mar 12, 2025

Allegation investigated: Illegal Eviction Facility staff are not meeting there residents dietary needs

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to commence a complaint investigation. LPA identified herself and explained the purpose of the visit with Staff Justin Clemeno. Administrator Susan and Ulysis Baalresponded to the facility to assist with the visit. LPA requested a copy of R1's file. LPA interviewed staff. Based on interviews and record review, facility did not evict R1. It is undetermined whether or not R1 was evicted. Rp could not provide a copy of an eviction notice and LPA did not locate an eviction notice in R1's file. Based on interviews, R1 is being fed 3 meals a day and snacks in between. It is unknown if there was a time R1 was not fed a meal or a snack. Unsubstantiated Based on record reviews and interviews, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 24-AS-20241121093506

Type of visit: Required - 1 Year

Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct the Annual Inspection. LPA met with Administrator Susan Baal and inform her the purpose of the visit. LPA toured the facility with Administrator. Facility appeared clean with no obstruction or fire clearance issues. All common areas have adequate seating and lighting. Resident bedrooms toured, rooms observed to have all required accommodations. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available for residents. Smoke detector and carbon monoxide detectors observed operational during inspection. Fire extinguisher present with a purchased date of 3/2024. Water temperature observed to measure at 111 degrees F. No deficiencies were observed.the state’s words, verbatim · CDSS document, May 24, 2024